Contact Form
1 error prohibited this ticket from being saved
There were problems with the following fields:
Full Name
Email address
How may we assist you?
...
Ask a question
Book a demo
Request a quote
Request a feature
Report a bug
Make a complaint
Request user guide
<div class="control-group ticket_section"> <label class=" control-label cf_phone_number_767862-label " for="helpdesk_ticket_cf_phone_number_767862">Phone Number</label> <div class="controls "> <input class=" text section_field span12" placeholder="" type="text" name="helpdesk_ticket[custom_field][cf_phone_number_767862]" id="helpdesk_ticket_custom_field_cf_phone_number_767862" /> </div> </div> <div class="control-group ticket_section"> <label class=" required control-label cf_occupation_767862-label " for="helpdesk_ticket_cf_occupation_767862">Occupation</label> <div class="controls "> <select class=" required dropdown_blank section_field" data-placeholder="..." name="helpdesk_ticket[custom_field][cf_occupation_767862]" id="helpdesk_ticket_custom_field_cf_occupation_767862"><option value="">...</option> <option data-id="35000677596" value="radiologist">radiologist</option> <option data-id="35001082549" value="neuroradiologist">neuroradiologist</option> <option data-id="35001082550" value="neurosurgeon">neurosurgeon</option> <option data-id="35001082551" value="urologist">urologist</option> <option data-id="35000677597" value="MRI specialist">MRI specialist</option> <option data-id="35001082552" value="researcher">researcher</option> <option data-id="35000677598" value="healthcare IT">healthcare IT</option> <option data-id="35000677599" value="manager/owner">manager/owner</option> <option data-id="35001082553" value="distributor">distributor</option> <option data-id="35000677600" value="student">student</option> <option data-id="35000677601" value="other">other</option></select> </div> </div> <div class="control-group ticket_section"> <label class=" control-label cf_country625518_767862-label " for="helpdesk_ticket_cf_country625518_767862">Country*</label> <div class="controls "> <select class=" dropdown_blank section_field" data-placeholder="..." name="helpdesk_ticket[custom_field][cf_country625518_767862]" id="helpdesk_ticket_custom_field_cf_country625518_767862"><option value="">...</option> <option data-id="35001095678" value="Afghanistan">Afghanistan</option> <option data-id="35001095679" value="Albania">Albania</option> <option data-id="35001095680" value="Algeria">Algeria</option> <option data-id="35001095681" value="Andorra">Andorra</option> <option data-id="35001095682" value="Angola">Angola</option> <option data-id="35001095683" value="Antigua and Barbuda">Antigua and Barbuda</option> <option data-id="35001095684" value="Argentina">Argentina</option> <option data-id="35001095685" value="Armenia">Armenia</option> <option data-id="35001095686" value="Australia">Australia</option> <option data-id="35001095687" value="Austria">Austria</option> <option data-id="35001095688" value="Azerbaijan">Azerbaijan</option> <option data-id="35001095689" value="Bahamas">Bahamas</option> <option data-id="35001095690" value="Bahrain">Bahrain</option> <option data-id="35001095691" value="Bangladesh">Bangladesh</option> <option data-id="35001095692" value="Barbados">Barbados</option> <option data-id="35001095693" value="Belarus">Belarus</option> <option data-id="35001095694" value="Belgium">Belgium</option> <option data-id="35001095695" value="Belize">Belize</option> <option data-id="35001095696" value="Benin">Benin</option> <option data-id="35001095697" value="Bhutan">Bhutan</option> <option data-id="35001095698" value="Bolivia">Bolivia</option> <option data-id="35001095699" value="Bosnia and Herzegovina">Bosnia and Herzegovina</option> <option data-id="35001095700" value="Botswana">Botswana</option> <option data-id="35001095701" value="Brazil">Brazil</option> <option data-id="35001095702" value="Brunei">Brunei</option> <option data-id="35001095703" value="Bulgaria">Bulgaria</option> <option data-id="35001095704" value="Burkina Faso">Burkina Faso</option> <option data-id="35001095705" value="Burundi">Burundi</option> <option data-id="35001095706" value="Cabo Verde">Cabo Verde</option> <option data-id="35001095707" value="Cambodia">Cambodia</option> <option data-id="35001095708" value="Cameroon">Cameroon</option> <option data-id="35001095709" value="Canada">Canada</option> <option data-id="35001095710" value="Central African Republic">Central African Republic</option> <option data-id="35001095711" value="Chad">Chad</option> <option data-id="35001095712" value="Chile">Chile</option> <option data-id="35001095713" value="China">China</option> <option data-id="35001095714" value="Colombia">Colombia</option> <option data-id="35001095715" value="Comoros">Comoros</option> <option data-id="35001095716" value="Congo, Democratic Republic of the">Congo, Democratic Republic of the</option> <option data-id="35001095717" value="Congo, Republic of the">Congo, Republic of the</option> <option data-id="35001095718" value="Costa Rica">Costa Rica</option> <option data-id="35001095719" value="Croatia">Croatia</option> <option data-id="35001095720" value="Cuba">Cuba</option> <option data-id="35001095721" value="Cyprus">Cyprus</option> <option data-id="35001095722" value="Czech Republic">Czech Republic</option> <option data-id="35001095723" value="Denmark">Denmark</option> <option data-id="35001095724" value="Djibouti">Djibouti</option> <option data-id="35001095725" value="Dominica">Dominica</option> <option data-id="35001095726" value="Dominican Republic">Dominican Republic</option> <option data-id="35001095727" value="Ecuador">Ecuador</option> <option data-id="35001095728" value="Egypt">Egypt</option> <option data-id="35001095729" value="El Salvador">El Salvador</option> <option data-id="35001095730" value="Equatorial Guinea">Equatorial Guinea</option> <option data-id="35001095731" value="Eritrea">Eritrea</option> <option data-id="35001095732" value="Estonia">Estonia</option> <option data-id="35001095733" value="Eswatini">Eswatini</option> <option data-id="35001095734" value="Ethiopia">Ethiopia</option> <option data-id="35001095735" value="Fiji">Fiji</option> <option data-id="35001095736" value="Finland">Finland</option> <option data-id="35001095737" value="France">France</option> <option data-id="35001095738" value="Gabon">Gabon</option> <option data-id="35001095739" value="Gambia">Gambia</option> <option data-id="35001095740" value="Georgia">Georgia</option> <option data-id="35001095741" value="Germany">Germany</option> <option data-id="35001095742" value="Ghana">Ghana</option> <option data-id="35001095743" value="Greece">Greece</option> <option data-id="35001095744" value="Grenada">Grenada</option> <option data-id="35001095745" value="Guatemala">Guatemala</option> <option data-id="35001095746" value="Guinea">Guinea</option> <option data-id="35001095747" value="Guinea-Bissau">Guinea-Bissau</option> <option data-id="35001095748" value="Guyana">Guyana</option> <option data-id="35001095749" value="Haiti">Haiti</option> <option data-id="35001095750" value="Honduras">Honduras</option> <option data-id="35001095751" value="Hungary">Hungary</option> <option data-id="35001095752" value="Iceland">Iceland</option> <option data-id="35001095753" value="India">India</option> <option data-id="35001095754" value="Indonesia">Indonesia</option> <option data-id="35001095755" value="Iran">Iran</option> <option data-id="35001095756" value="Iraq">Iraq</option> <option data-id="35001095757" value="Ireland">Ireland</option> <option data-id="35001095758" value="Israel">Israel</option> <option data-id="35001095759" value="Italy">Italy</option> <option data-id="35001095760" value="Jamaica">Jamaica</option> <option data-id="35001095761" value="Japan">Japan</option> <option data-id="35001095762" value="Jordan">Jordan</option> <option data-id="35001095763" value="Kazakhstan">Kazakhstan</option> <option data-id="35001095764" value="Kenya">Kenya</option> <option data-id="35001095765" value="Kiribati">Kiribati</option> <option data-id="35001095766" value="Korea, North">Korea, North</option> <option data-id="35001095767" value="Korea, South">Korea, South</option> <option data-id="35001095768" value="Kosovo">Kosovo</option> <option data-id="35001095769" value="Kuwait">Kuwait</option> <option data-id="35001095770" value="Kyrgyzstan">Kyrgyzstan</option> <option data-id="35001095771" value="Laos">Laos</option> <option data-id="35001095772" value="Latvia">Latvia</option> <option data-id="35001095773" value="Lebanon">Lebanon</option> <option data-id="35001095774" value="Lesotho">Lesotho</option> <option data-id="35001095775" value="Liberia">Liberia</option> <option data-id="35001095776" value="Libya">Libya</option> <option data-id="35001095777" value="Liechtenstein">Liechtenstein</option> <option data-id="35001095778" value="Lithuania">Lithuania</option> <option data-id="35001095779" value="Luxembourg">Luxembourg</option> <option data-id="35001095780" value="Madagascar">Madagascar</option> <option data-id="35001095781" value="Malawi">Malawi</option> <option data-id="35001095782" value="Malaysia">Malaysia</option> <option data-id="35001095783" value="Maldives">Maldives</option> <option data-id="35001095784" value="Mali">Mali</option> <option data-id="35001095785" value="Malta">Malta</option> <option data-id="35001095786" value="Marshall Islands">Marshall Islands</option> <option data-id="35001095787" value="Mauritania">Mauritania</option> <option data-id="35001095788" value="Mauritius">Mauritius</option> <option data-id="35001095789" value="Mexico">Mexico</option> <option data-id="35001095790" value="Micronesia">Micronesia</option> <option data-id="35001095791" value="Moldova">Moldova</option> <option data-id="35001095792" value="Monaco">Monaco</option> <option data-id="35001095793" value="Mongolia">Mongolia</option> <option data-id="35001095794" value="Montenegro">Montenegro</option> <option data-id="35001095795" value="Morocco">Morocco</option> <option data-id="35001095796" value="Mozambique">Mozambique</option> <option data-id="35001095797" value="Myanmar">Myanmar</option> <option data-id="35001095798" value="Namibia">Namibia</option> <option data-id="35001095799" value="Nauru">Nauru</option> <option data-id="35001095800" value="Nepal">Nepal</option> <option data-id="35001095801" value="Netherlands">Netherlands</option> <option data-id="35001095802" value="New Zealand">New Zealand</option> <option data-id="35001095803" value="Nicaragua">Nicaragua</option> <option data-id="35001095804" value="Niger">Niger</option> <option data-id="35001095805" value="Nigeria">Nigeria</option> <option data-id="35001095806" value="North Macedonia">North Macedonia</option> <option data-id="35001095807" value="Norway">Norway</option> <option data-id="35001095808" value="Oman">Oman</option> <option data-id="35001095809" value="Pakistan">Pakistan</option> <option data-id="35001095810" value="Palau">Palau</option> <option data-id="35001095811" value="Palestine">Palestine</option> <option data-id="35001095812" value="Panama">Panama</option> <option data-id="35001095813" value="Papua New Guinea">Papua New Guinea</option> <option data-id="35001095814" value="Paraguay">Paraguay</option> <option data-id="35001095815" value="Peru">Peru</option> <option data-id="35001095816" value="Philippines">Philippines</option> <option data-id="35001095817" value="Poland">Poland</option> <option data-id="35001095818" value="Portugal">Portugal</option> <option data-id="35001095819" value="Qatar">Qatar</option> <option data-id="35001095820" value="Romania">Romania</option> <option data-id="35001095821" value="Russia">Russia</option> <option data-id="35001095822" value="Rwanda">Rwanda</option> <option data-id="35001095823" value="Saint Kitts and Nevis">Saint Kitts and Nevis</option> <option data-id="35001095824" value="Saint Lucia">Saint Lucia</option> <option data-id="35001095825" value="Saint Vincent and the Grenadines">Saint Vincent and the Grenadines</option> <option data-id="35001095826" value="Samoa">Samoa</option> <option data-id="35001095827" value="San Marino">San Marino</option> <option data-id="35001095828" value="Sao Tome and Principe">Sao Tome and Principe</option> <option data-id="35001095829" value="Saudi Arabia">Saudi Arabia</option> <option data-id="35001095830" value="Senegal">Senegal</option> <option data-id="35001095831" value="Serbia">Serbia</option> <option data-id="35001095832" value="Seychelles">Seychelles</option> <option data-id="35001095833" value="Sierra Leone">Sierra Leone</option> <option data-id="35001095834" value="Singapore">Singapore</option> <option data-id="35001095835" value="Slovakia">Slovakia</option> <option data-id="35001095836" value="Slovenia">Slovenia</option> <option data-id="35001095837" value="Solomon Islands">Solomon Islands</option> <option data-id="35001095838" value="Somalia">Somalia</option> <option data-id="35001095839" value="South Africa">South Africa</option> <option data-id="35001095840" value="South Sudan">South Sudan</option> <option data-id="35001095841" value="Spain">Spain</option> <option data-id="35001095842" value="Sri Lanka">Sri Lanka</option> <option data-id="35001095843" value="Sudan">Sudan</option> <option data-id="35001095844" value="Suriname">Suriname</option> <option data-id="35001095845" value="Sweden">Sweden</option> <option data-id="35001095846" value="Switzerland">Switzerland</option> <option data-id="35001095847" value="Syria">Syria</option> <option data-id="35001095848" value="Taiwan">Taiwan</option> <option data-id="35001095849" value="Tajikistan">Tajikistan</option> <option data-id="35001095850" value="Tanzania">Tanzania</option> <option data-id="35001095851" value="Thailand">Thailand</option> <option data-id="35001095852" value="Timor-Leste">Timor-Leste</option> <option data-id="35001095853" value="Togo">Togo</option> <option data-id="35001095854" value="Tonga">Tonga</option> <option data-id="35001095855" value="Trinidad and Tobago">Trinidad and Tobago</option> <option data-id="35001095856" value="Tunisia">Tunisia</option> <option data-id="35001095857" value="Turkey">Turkey</option> <option data-id="35001095858" value="Turkmenistan">Turkmenistan</option> <option data-id="35001095859" value="Tuvalu">Tuvalu</option> <option data-id="35001095860" value="Uganda">Uganda</option> <option data-id="35001095861" value="Ukraine">Ukraine</option> <option data-id="35001095862" value="United Arab Emirates">United Arab Emirates</option> <option data-id="35001095863" value="United Kingdom">United Kingdom</option> <option data-id="35001095864" value="United States">United States</option> <option data-id="35001095865" value="Uruguay">Uruguay</option> <option data-id="35001095866" value="Uzbekistan">Uzbekistan</option> <option data-id="35001095867" value="Vanuatu">Vanuatu</option> <option data-id="35001095868" value="Vatican City">Vatican City</option> <option data-id="35001095869" value="Venezuela">Venezuela</option> <option data-id="35001095870" value="Vietnam">Vietnam</option> <option data-id="35001095871" value="Yemen">Yemen</option> <option data-id="35001095872" value="Zambia">Zambia</option> <option data-id="35001095873" value="Zimbabwe">Zimbabwe</option></select> </div> </div> <div class="control-group ticket_section"> <label class=" required control-label cf_productservice_767862-label " for="helpdesk_ticket_cf_productservice_767862">Product/Service Interest</label> <div class="controls "> <select class=" required dropdown_blank section_field" data-placeholder="..." name="helpdesk_ticket[custom_field][cf_productservice_767862]" id="helpdesk_ticket_custom_field_cf_productservice_767862"><option value="">...</option> <option data-id="35001082635" value="Advantis Platform | Brain & Prostate">Advantis Platform | Brain & Prostate</option> <option data-id="35000677602" value="Advantis Platform | Brain (Brainance MD)">Advantis Platform | Brain (Brainance MD)</option> <option data-id="35001065978" value="Advantis Platform | Prostate">Advantis Platform | Prostate</option> <option data-id="35001082554" value="PACS interconnection">PACS interconnection</option> <option data-id="35001065979" value="Advantis Academy">Advantis Academy</option> <option data-id="35000677604" value="Website">Website</option> <option data-id="35001082555" value="User Guide / Instructions for Use & Documentation">User Guide / Instructions for Use & Documentation</option> <option data-id="35001082556" value="Quality Management System">Quality Management System</option> <option data-id="35000677605" value="Other">Other</option></select> </div> </div>
<div class="control-group ticket_section"> <label class=" required control-label cf_occupation_767862-label " for="helpdesk_ticket_cf_occupation_767862">Occupation</label> <div class="controls "> <select class=" required dropdown_blank section_field" data-placeholder="..." name="helpdesk_ticket[custom_field][cf_occupation_767862]" id="helpdesk_ticket_custom_field_cf_occupation_767862"><option value="">...</option> <option data-id="35000677596" value="radiologist">radiologist</option> <option data-id="35001082549" value="neuroradiologist">neuroradiologist</option> <option data-id="35001082550" value="neurosurgeon">neurosurgeon</option> <option data-id="35001082551" value="urologist">urologist</option> <option data-id="35000677597" value="MRI specialist">MRI specialist</option> <option data-id="35001082552" value="researcher">researcher</option> <option data-id="35000677598" value="healthcare IT">healthcare IT</option> <option data-id="35000677599" value="manager/owner">manager/owner</option> <option data-id="35001082553" value="distributor">distributor</option> <option data-id="35000677600" value="student">student</option> <option data-id="35000677601" value="other">other</option></select> </div> </div> <div class="control-group ticket_section"> <label class=" required control-label cf_productservice_767862-label " for="helpdesk_ticket_cf_productservice_767862">Product/Service Interest</label> <div class="controls "> <select class=" required dropdown_blank section_field" data-placeholder="..." name="helpdesk_ticket[custom_field][cf_productservice_767862]" id="helpdesk_ticket_custom_field_cf_productservice_767862"><option value="">...</option> <option data-id="35001082635" value="Advantis Platform | Brain & Prostate">Advantis Platform | Brain & Prostate</option> <option data-id="35000677602" value="Advantis Platform | Brain (Brainance MD)">Advantis Platform | Brain (Brainance MD)</option> <option data-id="35001065978" value="Advantis Platform | Prostate">Advantis Platform | Prostate</option> <option data-id="35001082554" value="PACS interconnection">PACS interconnection</option> <option data-id="35001065979" value="Advantis Academy">Advantis Academy</option> <option data-id="35000677604" value="Website">Website</option> <option data-id="35001082555" value="User Guide / Instructions for Use & Documentation">User Guide / Instructions for Use & Documentation</option> <option data-id="35001082556" value="Quality Management System">Quality Management System</option> <option data-id="35000677605" value="Other">Other</option></select> </div> </div> <div class="control-group ticket_section"> <label class=" control-label cf_date_767862-label " for="helpdesk_ticket_cf_date_767862">Preferred date for demo</label> <div class="controls support-date-field "> <input type="text" name="helpdesk_ticket[custom_field][cf_date_767862]" id="helpdesk_ticket_custom_field_cf_date_767862" class=" date section_field datepicker_popover" readonly="readonly" data-show-image="true" data-date-format="d M, yy" placeholder="" /> </div> </div> <div class="control-group ticket_section"> <label class=" control-label cf_country625518_767862-label " for="helpdesk_ticket_cf_country625518_767862">Country*</label> <div class="controls "> <select class=" dropdown_blank section_field" data-placeholder="..." name="helpdesk_ticket[custom_field][cf_country625518_767862]" id="helpdesk_ticket_custom_field_cf_country625518_767862"><option value="">...</option> <option data-id="35001095678" value="Afghanistan">Afghanistan</option> <option data-id="35001095679" value="Albania">Albania</option> <option data-id="35001095680" value="Algeria">Algeria</option> <option data-id="35001095681" value="Andorra">Andorra</option> <option data-id="35001095682" value="Angola">Angola</option> <option data-id="35001095683" value="Antigua and Barbuda">Antigua and Barbuda</option> <option data-id="35001095684" value="Argentina">Argentina</option> <option data-id="35001095685" value="Armenia">Armenia</option> <option data-id="35001095686" value="Australia">Australia</option> <option data-id="35001095687" value="Austria">Austria</option> <option data-id="35001095688" value="Azerbaijan">Azerbaijan</option> <option data-id="35001095689" value="Bahamas">Bahamas</option> <option data-id="35001095690" value="Bahrain">Bahrain</option> <option data-id="35001095691" value="Bangladesh">Bangladesh</option> <option data-id="35001095692" value="Barbados">Barbados</option> <option data-id="35001095693" value="Belarus">Belarus</option> <option data-id="35001095694" value="Belgium">Belgium</option> <option data-id="35001095695" value="Belize">Belize</option> <option data-id="35001095696" value="Benin">Benin</option> <option data-id="35001095697" value="Bhutan">Bhutan</option> <option data-id="35001095698" value="Bolivia">Bolivia</option> <option data-id="35001095699" value="Bosnia and Herzegovina">Bosnia and Herzegovina</option> <option data-id="35001095700" value="Botswana">Botswana</option> <option data-id="35001095701" value="Brazil">Brazil</option> <option data-id="35001095702" value="Brunei">Brunei</option> <option data-id="35001095703" value="Bulgaria">Bulgaria</option> <option data-id="35001095704" value="Burkina Faso">Burkina Faso</option> <option data-id="35001095705" value="Burundi">Burundi</option> <option data-id="35001095706" value="Cabo Verde">Cabo Verde</option> <option data-id="35001095707" value="Cambodia">Cambodia</option> <option data-id="35001095708" value="Cameroon">Cameroon</option> <option data-id="35001095709" value="Canada">Canada</option> <option data-id="35001095710" value="Central African Republic">Central African Republic</option> <option data-id="35001095711" value="Chad">Chad</option> <option data-id="35001095712" value="Chile">Chile</option> <option data-id="35001095713" value="China">China</option> <option data-id="35001095714" value="Colombia">Colombia</option> <option data-id="35001095715" value="Comoros">Comoros</option> <option data-id="35001095716" value="Congo, Democratic Republic of the">Congo, Democratic Republic of the</option> <option data-id="35001095717" value="Congo, Republic of the">Congo, Republic of the</option> <option data-id="35001095718" value="Costa Rica">Costa Rica</option> <option data-id="35001095719" value="Croatia">Croatia</option> <option data-id="35001095720" value="Cuba">Cuba</option> <option data-id="35001095721" value="Cyprus">Cyprus</option> <option data-id="35001095722" value="Czech Republic">Czech Republic</option> <option data-id="35001095723" value="Denmark">Denmark</option> <option data-id="35001095724" value="Djibouti">Djibouti</option> <option data-id="35001095725" value="Dominica">Dominica</option> <option data-id="35001095726" value="Dominican Republic">Dominican Republic</option> <option data-id="35001095727" value="Ecuador">Ecuador</option> <option data-id="35001095728" value="Egypt">Egypt</option> <option data-id="35001095729" value="El Salvador">El Salvador</option> <option data-id="35001095730" value="Equatorial Guinea">Equatorial Guinea</option> <option data-id="35001095731" value="Eritrea">Eritrea</option> <option data-id="35001095732" value="Estonia">Estonia</option> <option data-id="35001095733" value="Eswatini">Eswatini</option> <option data-id="35001095734" value="Ethiopia">Ethiopia</option> <option data-id="35001095735" value="Fiji">Fiji</option> <option data-id="35001095736" value="Finland">Finland</option> <option data-id="35001095737" value="France">France</option> <option data-id="35001095738" value="Gabon">Gabon</option> <option data-id="35001095739" value="Gambia">Gambia</option> <option data-id="35001095740" value="Georgia">Georgia</option> <option data-id="35001095741" value="Germany">Germany</option> <option data-id="35001095742" value="Ghana">Ghana</option> <option data-id="35001095743" value="Greece">Greece</option> <option data-id="35001095744" value="Grenada">Grenada</option> <option data-id="35001095745" value="Guatemala">Guatemala</option> <option data-id="35001095746" value="Guinea">Guinea</option> <option data-id="35001095747" value="Guinea-Bissau">Guinea-Bissau</option> <option data-id="35001095748" value="Guyana">Guyana</option> <option data-id="35001095749" value="Haiti">Haiti</option> <option data-id="35001095750" value="Honduras">Honduras</option> <option data-id="35001095751" value="Hungary">Hungary</option> <option data-id="35001095752" value="Iceland">Iceland</option> <option data-id="35001095753" value="India">India</option> <option data-id="35001095754" value="Indonesia">Indonesia</option> <option data-id="35001095755" value="Iran">Iran</option> <option data-id="35001095756" value="Iraq">Iraq</option> <option data-id="35001095757" value="Ireland">Ireland</option> <option data-id="35001095758" value="Israel">Israel</option> <option data-id="35001095759" value="Italy">Italy</option> <option data-id="35001095760" value="Jamaica">Jamaica</option> <option data-id="35001095761" value="Japan">Japan</option> <option data-id="35001095762" value="Jordan">Jordan</option> <option data-id="35001095763" value="Kazakhstan">Kazakhstan</option> <option data-id="35001095764" value="Kenya">Kenya</option> <option data-id="35001095765" value="Kiribati">Kiribati</option> <option data-id="35001095766" value="Korea, North">Korea, North</option> <option data-id="35001095767" value="Korea, South">Korea, South</option> <option data-id="35001095768" value="Kosovo">Kosovo</option> <option data-id="35001095769" value="Kuwait">Kuwait</option> <option data-id="35001095770" value="Kyrgyzstan">Kyrgyzstan</option> <option data-id="35001095771" value="Laos">Laos</option> <option data-id="35001095772" value="Latvia">Latvia</option> <option data-id="35001095773" value="Lebanon">Lebanon</option> <option data-id="35001095774" value="Lesotho">Lesotho</option> <option data-id="35001095775" value="Liberia">Liberia</option> <option data-id="35001095776" value="Libya">Libya</option> <option data-id="35001095777" value="Liechtenstein">Liechtenstein</option> <option data-id="35001095778" value="Lithuania">Lithuania</option> <option data-id="35001095779" value="Luxembourg">Luxembourg</option> <option data-id="35001095780" value="Madagascar">Madagascar</option> <option data-id="35001095781" value="Malawi">Malawi</option> <option data-id="35001095782" value="Malaysia">Malaysia</option> <option data-id="35001095783" value="Maldives">Maldives</option> <option data-id="35001095784" value="Mali">Mali</option> <option data-id="35001095785" value="Malta">Malta</option> <option data-id="35001095786" value="Marshall Islands">Marshall Islands</option> <option data-id="35001095787" value="Mauritania">Mauritania</option> <option data-id="35001095788" value="Mauritius">Mauritius</option> <option data-id="35001095789" value="Mexico">Mexico</option> <option data-id="35001095790" value="Micronesia">Micronesia</option> <option data-id="35001095791" value="Moldova">Moldova</option> <option data-id="35001095792" value="Monaco">Monaco</option> <option data-id="35001095793" value="Mongolia">Mongolia</option> <option data-id="35001095794" value="Montenegro">Montenegro</option> <option data-id="35001095795" value="Morocco">Morocco</option> <option data-id="35001095796" value="Mozambique">Mozambique</option> <option data-id="35001095797" value="Myanmar">Myanmar</option> <option data-id="35001095798" value="Namibia">Namibia</option> <option data-id="35001095799" value="Nauru">Nauru</option> <option data-id="35001095800" value="Nepal">Nepal</option> <option data-id="35001095801" value="Netherlands">Netherlands</option> <option data-id="35001095802" value="New Zealand">New Zealand</option> <option data-id="35001095803" value="Nicaragua">Nicaragua</option> <option data-id="35001095804" value="Niger">Niger</option> <option data-id="35001095805" value="Nigeria">Nigeria</option> <option data-id="35001095806" value="North Macedonia">North Macedonia</option> <option data-id="35001095807" value="Norway">Norway</option> <option data-id="35001095808" value="Oman">Oman</option> <option data-id="35001095809" value="Pakistan">Pakistan</option> <option data-id="35001095810" value="Palau">Palau</option> <option data-id="35001095811" value="Palestine">Palestine</option> <option data-id="35001095812" value="Panama">Panama</option> <option data-id="35001095813" value="Papua New Guinea">Papua New Guinea</option> <option data-id="35001095814" value="Paraguay">Paraguay</option> <option data-id="35001095815" value="Peru">Peru</option> <option data-id="35001095816" value="Philippines">Philippines</option> <option data-id="35001095817" value="Poland">Poland</option> <option data-id="35001095818" value="Portugal">Portugal</option> <option data-id="35001095819" value="Qatar">Qatar</option> <option data-id="35001095820" value="Romania">Romania</option> <option data-id="35001095821" value="Russia">Russia</option> <option data-id="35001095822" value="Rwanda">Rwanda</option> <option data-id="35001095823" value="Saint Kitts and Nevis">Saint Kitts and Nevis</option> <option data-id="35001095824" value="Saint Lucia">Saint Lucia</option> <option data-id="35001095825" value="Saint Vincent and the Grenadines">Saint Vincent and the Grenadines</option> <option data-id="35001095826" value="Samoa">Samoa</option> <option data-id="35001095827" value="San Marino">San Marino</option> <option data-id="35001095828" value="Sao Tome and Principe">Sao Tome and Principe</option> <option data-id="35001095829" value="Saudi Arabia">Saudi Arabia</option> <option data-id="35001095830" value="Senegal">Senegal</option> <option data-id="35001095831" value="Serbia">Serbia</option> <option data-id="35001095832" value="Seychelles">Seychelles</option> <option data-id="35001095833" value="Sierra Leone">Sierra Leone</option> <option data-id="35001095834" value="Singapore">Singapore</option> <option data-id="35001095835" value="Slovakia">Slovakia</option> <option data-id="35001095836" value="Slovenia">Slovenia</option> <option data-id="35001095837" value="Solomon Islands">Solomon Islands</option> <option data-id="35001095838" value="Somalia">Somalia</option> <option data-id="35001095839" value="South Africa">South Africa</option> <option data-id="35001095840" value="South Sudan">South Sudan</option> <option data-id="35001095841" value="Spain">Spain</option> <option data-id="35001095842" value="Sri Lanka">Sri Lanka</option> <option data-id="35001095843" value="Sudan">Sudan</option> <option data-id="35001095844" value="Suriname">Suriname</option> <option data-id="35001095845" value="Sweden">Sweden</option> <option data-id="35001095846" value="Switzerland">Switzerland</option> <option data-id="35001095847" value="Syria">Syria</option> <option data-id="35001095848" value="Taiwan">Taiwan</option> <option data-id="35001095849" value="Tajikistan">Tajikistan</option> <option data-id="35001095850" value="Tanzania">Tanzania</option> <option data-id="35001095851" value="Thailand">Thailand</option> <option data-id="35001095852" value="Timor-Leste">Timor-Leste</option> <option data-id="35001095853" value="Togo">Togo</option> <option data-id="35001095854" value="Tonga">Tonga</option> <option data-id="35001095855" value="Trinidad and Tobago">Trinidad and Tobago</option> <option data-id="35001095856" value="Tunisia">Tunisia</option> <option data-id="35001095857" value="Turkey">Turkey</option> <option data-id="35001095858" value="Turkmenistan">Turkmenistan</option> <option data-id="35001095859" value="Tuvalu">Tuvalu</option> <option data-id="35001095860" value="Uganda">Uganda</option> <option data-id="35001095861" value="Ukraine">Ukraine</option> <option data-id="35001095862" value="United Arab Emirates">United Arab Emirates</option> <option data-id="35001095863" value="United Kingdom">United Kingdom</option> <option data-id="35001095864" value="United States">United States</option> <option data-id="35001095865" value="Uruguay">Uruguay</option> <option data-id="35001095866" value="Uzbekistan">Uzbekistan</option> <option data-id="35001095867" value="Vanuatu">Vanuatu</option> <option data-id="35001095868" value="Vatican City">Vatican City</option> <option data-id="35001095869" value="Venezuela">Venezuela</option> <option data-id="35001095870" value="Vietnam">Vietnam</option> <option data-id="35001095871" value="Yemen">Yemen</option> <option data-id="35001095872" value="Zambia">Zambia</option> <option data-id="35001095873" value="Zimbabwe">Zimbabwe</option></select> </div> </div> <div class="control-group ticket_section"> <label class=" required control-label cf_company_institution_767862-label " for="helpdesk_ticket_cf_company_institution_767862">Company / Institution</label> <div class="controls "> <input class=" required text section_field span12" placeholder="" type="text" name="helpdesk_ticket[custom_field][cf_company_institution_767862]" id="helpdesk_ticket_custom_field_cf_company_institution_767862" /> </div> </div> <div class="control-group ticket_section"> <label class=" control-label cf_phone_number_767862-label " for="helpdesk_ticket_cf_phone_number_767862">Phone Number</label> <div class="controls "> <input class=" text section_field span12" placeholder="" type="text" name="helpdesk_ticket[custom_field][cf_phone_number_767862]" id="helpdesk_ticket_custom_field_cf_phone_number_767862" /> </div> </div>
<div class="control-group ticket_section"> <label class=" control-label cf_country625518_767862-label " for="helpdesk_ticket_cf_country625518_767862">Country*</label> <div class="controls "> <select class=" dropdown_blank section_field" data-placeholder="..." name="helpdesk_ticket[custom_field][cf_country625518_767862]" id="helpdesk_ticket_custom_field_cf_country625518_767862"><option value="">...</option> <option data-id="35001095678" value="Afghanistan">Afghanistan</option> <option data-id="35001095679" value="Albania">Albania</option> <option data-id="35001095680" value="Algeria">Algeria</option> <option data-id="35001095681" value="Andorra">Andorra</option> <option data-id="35001095682" value="Angola">Angola</option> <option data-id="35001095683" value="Antigua and Barbuda">Antigua and Barbuda</option> <option data-id="35001095684" value="Argentina">Argentina</option> <option data-id="35001095685" value="Armenia">Armenia</option> <option data-id="35001095686" value="Australia">Australia</option> <option data-id="35001095687" value="Austria">Austria</option> <option data-id="35001095688" value="Azerbaijan">Azerbaijan</option> <option data-id="35001095689" value="Bahamas">Bahamas</option> <option data-id="35001095690" value="Bahrain">Bahrain</option> <option data-id="35001095691" value="Bangladesh">Bangladesh</option> <option data-id="35001095692" value="Barbados">Barbados</option> <option data-id="35001095693" value="Belarus">Belarus</option> <option data-id="35001095694" value="Belgium">Belgium</option> <option data-id="35001095695" value="Belize">Belize</option> <option data-id="35001095696" value="Benin">Benin</option> <option data-id="35001095697" value="Bhutan">Bhutan</option> <option data-id="35001095698" value="Bolivia">Bolivia</option> <option data-id="35001095699" value="Bosnia and Herzegovina">Bosnia and Herzegovina</option> <option data-id="35001095700" value="Botswana">Botswana</option> <option data-id="35001095701" value="Brazil">Brazil</option> <option data-id="35001095702" value="Brunei">Brunei</option> <option data-id="35001095703" value="Bulgaria">Bulgaria</option> <option data-id="35001095704" value="Burkina Faso">Burkina Faso</option> <option data-id="35001095705" value="Burundi">Burundi</option> <option data-id="35001095706" value="Cabo Verde">Cabo Verde</option> <option data-id="35001095707" value="Cambodia">Cambodia</option> <option data-id="35001095708" value="Cameroon">Cameroon</option> <option data-id="35001095709" value="Canada">Canada</option> <option data-id="35001095710" value="Central African Republic">Central African Republic</option> <option data-id="35001095711" value="Chad">Chad</option> <option data-id="35001095712" value="Chile">Chile</option> <option data-id="35001095713" value="China">China</option> <option data-id="35001095714" value="Colombia">Colombia</option> <option data-id="35001095715" value="Comoros">Comoros</option> <option data-id="35001095716" value="Congo, Democratic Republic of the">Congo, Democratic Republic of the</option> <option data-id="35001095717" value="Congo, Republic of the">Congo, Republic of the</option> <option data-id="35001095718" value="Costa Rica">Costa Rica</option> <option data-id="35001095719" value="Croatia">Croatia</option> <option data-id="35001095720" value="Cuba">Cuba</option> <option data-id="35001095721" value="Cyprus">Cyprus</option> <option data-id="35001095722" value="Czech Republic">Czech Republic</option> <option data-id="35001095723" value="Denmark">Denmark</option> <option data-id="35001095724" value="Djibouti">Djibouti</option> <option data-id="35001095725" value="Dominica">Dominica</option> <option data-id="35001095726" value="Dominican Republic">Dominican Republic</option> <option data-id="35001095727" value="Ecuador">Ecuador</option> <option data-id="35001095728" value="Egypt">Egypt</option> <option data-id="35001095729" value="El Salvador">El Salvador</option> <option data-id="35001095730" value="Equatorial Guinea">Equatorial Guinea</option> <option data-id="35001095731" value="Eritrea">Eritrea</option> <option data-id="35001095732" value="Estonia">Estonia</option> <option data-id="35001095733" value="Eswatini">Eswatini</option> <option data-id="35001095734" value="Ethiopia">Ethiopia</option> <option data-id="35001095735" value="Fiji">Fiji</option> <option data-id="35001095736" value="Finland">Finland</option> <option data-id="35001095737" value="France">France</option> <option data-id="35001095738" value="Gabon">Gabon</option> <option data-id="35001095739" value="Gambia">Gambia</option> <option data-id="35001095740" value="Georgia">Georgia</option> <option data-id="35001095741" value="Germany">Germany</option> <option data-id="35001095742" value="Ghana">Ghana</option> <option data-id="35001095743" value="Greece">Greece</option> <option data-id="35001095744" value="Grenada">Grenada</option> <option data-id="35001095745" value="Guatemala">Guatemala</option> <option data-id="35001095746" value="Guinea">Guinea</option> <option data-id="35001095747" value="Guinea-Bissau">Guinea-Bissau</option> <option data-id="35001095748" value="Guyana">Guyana</option> <option data-id="35001095749" value="Haiti">Haiti</option> <option data-id="35001095750" value="Honduras">Honduras</option> <option data-id="35001095751" value="Hungary">Hungary</option> <option data-id="35001095752" value="Iceland">Iceland</option> <option data-id="35001095753" value="India">India</option> <option data-id="35001095754" value="Indonesia">Indonesia</option> <option data-id="35001095755" value="Iran">Iran</option> <option data-id="35001095756" value="Iraq">Iraq</option> <option data-id="35001095757" value="Ireland">Ireland</option> <option data-id="35001095758" value="Israel">Israel</option> <option data-id="35001095759" value="Italy">Italy</option> <option data-id="35001095760" value="Jamaica">Jamaica</option> <option data-id="35001095761" value="Japan">Japan</option> <option data-id="35001095762" value="Jordan">Jordan</option> <option data-id="35001095763" value="Kazakhstan">Kazakhstan</option> <option data-id="35001095764" value="Kenya">Kenya</option> <option data-id="35001095765" value="Kiribati">Kiribati</option> <option data-id="35001095766" value="Korea, North">Korea, North</option> <option data-id="35001095767" value="Korea, South">Korea, South</option> <option data-id="35001095768" value="Kosovo">Kosovo</option> <option data-id="35001095769" value="Kuwait">Kuwait</option> <option data-id="35001095770" value="Kyrgyzstan">Kyrgyzstan</option> <option data-id="35001095771" value="Laos">Laos</option> <option data-id="35001095772" value="Latvia">Latvia</option> <option data-id="35001095773" value="Lebanon">Lebanon</option> <option data-id="35001095774" value="Lesotho">Lesotho</option> <option data-id="35001095775" value="Liberia">Liberia</option> <option data-id="35001095776" value="Libya">Libya</option> <option data-id="35001095777" value="Liechtenstein">Liechtenstein</option> <option data-id="35001095778" value="Lithuania">Lithuania</option> <option data-id="35001095779" value="Luxembourg">Luxembourg</option> <option data-id="35001095780" value="Madagascar">Madagascar</option> <option data-id="35001095781" value="Malawi">Malawi</option> <option data-id="35001095782" value="Malaysia">Malaysia</option> <option data-id="35001095783" value="Maldives">Maldives</option> <option data-id="35001095784" value="Mali">Mali</option> <option data-id="35001095785" value="Malta">Malta</option> <option data-id="35001095786" value="Marshall Islands">Marshall Islands</option> <option data-id="35001095787" value="Mauritania">Mauritania</option> <option data-id="35001095788" value="Mauritius">Mauritius</option> <option data-id="35001095789" value="Mexico">Mexico</option> <option data-id="35001095790" value="Micronesia">Micronesia</option> <option data-id="35001095791" value="Moldova">Moldova</option> <option data-id="35001095792" value="Monaco">Monaco</option> <option data-id="35001095793" value="Mongolia">Mongolia</option> <option data-id="35001095794" value="Montenegro">Montenegro</option> <option data-id="35001095795" value="Morocco">Morocco</option> <option data-id="35001095796" value="Mozambique">Mozambique</option> <option data-id="35001095797" value="Myanmar">Myanmar</option> <option data-id="35001095798" value="Namibia">Namibia</option> <option data-id="35001095799" value="Nauru">Nauru</option> <option data-id="35001095800" value="Nepal">Nepal</option> <option data-id="35001095801" value="Netherlands">Netherlands</option> <option data-id="35001095802" value="New Zealand">New Zealand</option> <option data-id="35001095803" value="Nicaragua">Nicaragua</option> <option data-id="35001095804" value="Niger">Niger</option> <option data-id="35001095805" value="Nigeria">Nigeria</option> <option data-id="35001095806" value="North Macedonia">North Macedonia</option> <option data-id="35001095807" value="Norway">Norway</option> <option data-id="35001095808" value="Oman">Oman</option> <option data-id="35001095809" value="Pakistan">Pakistan</option> <option data-id="35001095810" value="Palau">Palau</option> <option data-id="35001095811" value="Palestine">Palestine</option> <option data-id="35001095812" value="Panama">Panama</option> <option data-id="35001095813" value="Papua New Guinea">Papua New Guinea</option> <option data-id="35001095814" value="Paraguay">Paraguay</option> <option data-id="35001095815" value="Peru">Peru</option> <option data-id="35001095816" value="Philippines">Philippines</option> <option data-id="35001095817" value="Poland">Poland</option> <option data-id="35001095818" value="Portugal">Portugal</option> <option data-id="35001095819" value="Qatar">Qatar</option> <option data-id="35001095820" value="Romania">Romania</option> <option data-id="35001095821" value="Russia">Russia</option> <option data-id="35001095822" value="Rwanda">Rwanda</option> <option data-id="35001095823" value="Saint Kitts and Nevis">Saint Kitts and Nevis</option> <option data-id="35001095824" value="Saint Lucia">Saint Lucia</option> <option data-id="35001095825" value="Saint Vincent and the Grenadines">Saint Vincent and the Grenadines</option> <option data-id="35001095826" value="Samoa">Samoa</option> <option data-id="35001095827" value="San Marino">San Marino</option> <option data-id="35001095828" value="Sao Tome and Principe">Sao Tome and Principe</option> <option data-id="35001095829" value="Saudi Arabia">Saudi Arabia</option> <option data-id="35001095830" value="Senegal">Senegal</option> <option data-id="35001095831" value="Serbia">Serbia</option> <option data-id="35001095832" value="Seychelles">Seychelles</option> <option data-id="35001095833" value="Sierra Leone">Sierra Leone</option> <option data-id="35001095834" value="Singapore">Singapore</option> <option data-id="35001095835" value="Slovakia">Slovakia</option> <option data-id="35001095836" value="Slovenia">Slovenia</option> <option data-id="35001095837" value="Solomon Islands">Solomon Islands</option> <option data-id="35001095838" value="Somalia">Somalia</option> <option data-id="35001095839" value="South Africa">South Africa</option> <option data-id="35001095840" value="South Sudan">South Sudan</option> <option data-id="35001095841" value="Spain">Spain</option> <option data-id="35001095842" value="Sri Lanka">Sri Lanka</option> <option data-id="35001095843" value="Sudan">Sudan</option> <option data-id="35001095844" value="Suriname">Suriname</option> <option data-id="35001095845" value="Sweden">Sweden</option> <option data-id="35001095846" value="Switzerland">Switzerland</option> <option data-id="35001095847" value="Syria">Syria</option> <option data-id="35001095848" value="Taiwan">Taiwan</option> <option data-id="35001095849" value="Tajikistan">Tajikistan</option> <option data-id="35001095850" value="Tanzania">Tanzania</option> <option data-id="35001095851" value="Thailand">Thailand</option> <option data-id="35001095852" value="Timor-Leste">Timor-Leste</option> <option data-id="35001095853" value="Togo">Togo</option> <option data-id="35001095854" value="Tonga">Tonga</option> <option data-id="35001095855" value="Trinidad and Tobago">Trinidad and Tobago</option> <option data-id="35001095856" value="Tunisia">Tunisia</option> <option data-id="35001095857" value="Turkey">Turkey</option> <option data-id="35001095858" value="Turkmenistan">Turkmenistan</option> <option data-id="35001095859" value="Tuvalu">Tuvalu</option> <option data-id="35001095860" value="Uganda">Uganda</option> <option data-id="35001095861" value="Ukraine">Ukraine</option> <option data-id="35001095862" value="United Arab Emirates">United Arab Emirates</option> <option data-id="35001095863" value="United Kingdom">United Kingdom</option> <option data-id="35001095864" value="United States">United States</option> <option data-id="35001095865" value="Uruguay">Uruguay</option> <option data-id="35001095866" value="Uzbekistan">Uzbekistan</option> <option data-id="35001095867" value="Vanuatu">Vanuatu</option> <option data-id="35001095868" value="Vatican City">Vatican City</option> <option data-id="35001095869" value="Venezuela">Venezuela</option> <option data-id="35001095870" value="Vietnam">Vietnam</option> <option data-id="35001095871" value="Yemen">Yemen</option> <option data-id="35001095872" value="Zambia">Zambia</option> <option data-id="35001095873" value="Zimbabwe">Zimbabwe</option></select> </div> </div> <div class="control-group ticket_section"> <label class=" required control-label cf_occupation_767862-label " for="helpdesk_ticket_cf_occupation_767862">Occupation</label> <div class="controls "> <select class=" required dropdown_blank section_field" data-placeholder="..." name="helpdesk_ticket[custom_field][cf_occupation_767862]" id="helpdesk_ticket_custom_field_cf_occupation_767862"><option value="">...</option> <option data-id="35000677596" value="radiologist">radiologist</option> <option data-id="35001082549" value="neuroradiologist">neuroradiologist</option> <option data-id="35001082550" value="neurosurgeon">neurosurgeon</option> <option data-id="35001082551" value="urologist">urologist</option> <option data-id="35000677597" value="MRI specialist">MRI specialist</option> <option data-id="35001082552" value="researcher">researcher</option> <option data-id="35000677598" value="healthcare IT">healthcare IT</option> <option data-id="35000677599" value="manager/owner">manager/owner</option> <option data-id="35001082553" value="distributor">distributor</option> <option data-id="35000677600" value="student">student</option> <option data-id="35000677601" value="other">other</option></select> </div> </div> <div class="control-group ticket_section"> <label class=" required control-label cf_productservice_767862-label " for="helpdesk_ticket_cf_productservice_767862">Product/Service Interest</label> <div class="controls "> <select class=" required dropdown_blank section_field" data-placeholder="..." name="helpdesk_ticket[custom_field][cf_productservice_767862]" id="helpdesk_ticket_custom_field_cf_productservice_767862"><option value="">...</option> <option data-id="35001082635" value="Advantis Platform | Brain & Prostate">Advantis Platform | Brain & Prostate</option> <option data-id="35000677602" value="Advantis Platform | Brain (Brainance MD)">Advantis Platform | Brain (Brainance MD)</option> <option data-id="35001065978" value="Advantis Platform | Prostate">Advantis Platform | Prostate</option> <option data-id="35001082554" value="PACS interconnection">PACS interconnection</option> <option data-id="35001065979" value="Advantis Academy">Advantis Academy</option> <option data-id="35000677604" value="Website">Website</option> <option data-id="35001082555" value="User Guide / Instructions for Use & Documentation">User Guide / Instructions for Use & Documentation</option> <option data-id="35001082556" value="Quality Management System">Quality Management System</option> <option data-id="35000677605" value="Other">Other</option></select> </div> </div> <div class="control-group ticket_section"> <label class=" required control-label cf_company_institution_767862-label " for="helpdesk_ticket_cf_company_institution_767862">Company / Institution</label> <div class="controls "> <input class=" required text section_field span12" placeholder="" type="text" name="helpdesk_ticket[custom_field][cf_company_institution_767862]" id="helpdesk_ticket_custom_field_cf_company_institution_767862" /> </div> </div> <div class="control-group ticket_section"> <label class=" control-label cf_phone_number_767862-label " for="helpdesk_ticket_cf_phone_number_767862">Phone Number</label> <div class="controls "> <input class=" text section_field span12" placeholder="" type="text" name="helpdesk_ticket[custom_field][cf_phone_number_767862]" id="helpdesk_ticket_custom_field_cf_phone_number_767862" /> </div> </div> <div class="control-group ticket_section"> <label class=" control-label cf_number_of_exams_per_month_767862-label " for="helpdesk_ticket_cf_number_of_exams_per_month_767862">Number of exams per month</label> <div class="controls "> <select class=" dropdown_blank section_field" data-placeholder="..." name="helpdesk_ticket[custom_field][cf_number_of_exams_per_month_767862]" id="helpdesk_ticket_custom_field_cf_number_of_exams_per_month_767862"><option value="">...</option> <option data-id="35001082669" value="I don't know">I don't know</option> <option data-id="35001082636" value="Up to 20 / month">Up to 20 / month</option> <option data-id="35001082637" value="Up to 50 / month">Up to 50 / month</option> <option data-id="35001082638" value="Up to 100 / month">Up to 100 / month</option> <option data-id="35001082639" value="Up to 200 / month">Up to 200 / month</option> <option data-id="35001082640" value="Up to 300 / month">Up to 300 / month</option> <option data-id="35001082641" value="Up to 400 / month">Up to 400 / month</option> <option data-id="35001082642" value="Up to 500 / month">Up to 500 / month</option> <option data-id="35001082643" value="Up to 750 / month">Up to 750 / month</option> <option data-id="35001082644" value="Up to 1000 / month">Up to 1000 / month</option> <option data-id="35001082645" value="More than 1000 / month">More than 1000 / month</option></select> </div> </div> <div class="control-group ticket_section"> <label class=" control-label cf_number_of_users679964_767862-label " for="helpdesk_ticket_cf_number_of_users679964_767862">Number of users</label> <div class="controls "> <select class=" dropdown_blank section_field" data-placeholder="..." name="helpdesk_ticket[custom_field][cf_number_of_users679964_767862]" id="helpdesk_ticket_custom_field_cf_number_of_users679964_767862"><option value="">...</option> <option data-id="35001082668" value="I don't know">I don't know</option> <option data-id="35001082646" value="1">1</option> <option data-id="35001082647" value="2">2</option> <option data-id="35001082648" value="3">3</option> <option data-id="35001082649" value="4">4</option> <option data-id="35001082650" value="5">5</option> <option data-id="35001082651" value="6">6</option> <option data-id="35001082652" value="7">7</option> <option data-id="35001082653" value="8">8</option> <option data-id="35001082654" value="9">9</option> <option data-id="35001082655" value="10">10</option> <option data-id="35001082656" value="11">11</option> <option data-id="35001082657" value="12">12</option> <option data-id="35001082658" value="13">13</option> <option data-id="35001082659" value="14">14</option> <option data-id="35001082660" value="15">15</option> <option data-id="35001082661" value="16">16</option> <option data-id="35001082662" value="17">17</option> <option data-id="35001082663" value="18">18</option> <option data-id="35001082664" value="19">19</option> <option data-id="35001082665" value="20">20</option> <option data-id="35001082666" value="20+">20+</option></select> </div> </div>
<div class="control-group ticket_section"> <label class=" required control-label cf_occupation_767862-label " for="helpdesk_ticket_cf_occupation_767862">Occupation</label> <div class="controls "> <select class=" required dropdown_blank section_field" data-placeholder="..." name="helpdesk_ticket[custom_field][cf_occupation_767862]" id="helpdesk_ticket_custom_field_cf_occupation_767862"><option value="">...</option> <option data-id="35000677596" value="radiologist">radiologist</option> <option data-id="35001082549" value="neuroradiologist">neuroradiologist</option> <option data-id="35001082550" value="neurosurgeon">neurosurgeon</option> <option data-id="35001082551" value="urologist">urologist</option> <option data-id="35000677597" value="MRI specialist">MRI specialist</option> <option data-id="35001082552" value="researcher">researcher</option> <option data-id="35000677598" value="healthcare IT">healthcare IT</option> <option data-id="35000677599" value="manager/owner">manager/owner</option> <option data-id="35001082553" value="distributor">distributor</option> <option data-id="35000677600" value="student">student</option> <option data-id="35000677601" value="other">other</option></select> </div> </div> <div class="control-group ticket_section"> <label class=" required control-label cf_company_institution_767862-label " for="helpdesk_ticket_cf_company_institution_767862">Company / Institution</label> <div class="controls "> <input class=" required text section_field span12" placeholder="" type="text" name="helpdesk_ticket[custom_field][cf_company_institution_767862]" id="helpdesk_ticket_custom_field_cf_company_institution_767862" /> </div> </div> <div class="control-group ticket_section"> <label class=" control-label cf_country625518_767862-label " for="helpdesk_ticket_cf_country625518_767862">Country*</label> <div class="controls "> <select class=" dropdown_blank section_field" data-placeholder="..." name="helpdesk_ticket[custom_field][cf_country625518_767862]" id="helpdesk_ticket_custom_field_cf_country625518_767862"><option value="">...</option> <option data-id="35001095678" value="Afghanistan">Afghanistan</option> <option data-id="35001095679" value="Albania">Albania</option> <option data-id="35001095680" value="Algeria">Algeria</option> <option data-id="35001095681" value="Andorra">Andorra</option> <option data-id="35001095682" value="Angola">Angola</option> <option data-id="35001095683" value="Antigua and Barbuda">Antigua and Barbuda</option> <option data-id="35001095684" value="Argentina">Argentina</option> <option data-id="35001095685" value="Armenia">Armenia</option> <option data-id="35001095686" value="Australia">Australia</option> <option data-id="35001095687" value="Austria">Austria</option> <option data-id="35001095688" value="Azerbaijan">Azerbaijan</option> <option data-id="35001095689" value="Bahamas">Bahamas</option> <option data-id="35001095690" value="Bahrain">Bahrain</option> <option data-id="35001095691" value="Bangladesh">Bangladesh</option> <option data-id="35001095692" value="Barbados">Barbados</option> <option data-id="35001095693" value="Belarus">Belarus</option> <option data-id="35001095694" value="Belgium">Belgium</option> <option data-id="35001095695" value="Belize">Belize</option> <option data-id="35001095696" value="Benin">Benin</option> <option data-id="35001095697" value="Bhutan">Bhutan</option> <option data-id="35001095698" value="Bolivia">Bolivia</option> <option data-id="35001095699" value="Bosnia and Herzegovina">Bosnia and Herzegovina</option> <option data-id="35001095700" value="Botswana">Botswana</option> <option data-id="35001095701" value="Brazil">Brazil</option> <option data-id="35001095702" value="Brunei">Brunei</option> <option data-id="35001095703" value="Bulgaria">Bulgaria</option> <option data-id="35001095704" value="Burkina Faso">Burkina Faso</option> <option data-id="35001095705" value="Burundi">Burundi</option> <option data-id="35001095706" value="Cabo Verde">Cabo Verde</option> <option data-id="35001095707" value="Cambodia">Cambodia</option> <option data-id="35001095708" value="Cameroon">Cameroon</option> <option data-id="35001095709" value="Canada">Canada</option> <option data-id="35001095710" value="Central African Republic">Central African Republic</option> <option data-id="35001095711" value="Chad">Chad</option> <option data-id="35001095712" value="Chile">Chile</option> <option data-id="35001095713" value="China">China</option> <option data-id="35001095714" value="Colombia">Colombia</option> <option data-id="35001095715" value="Comoros">Comoros</option> <option data-id="35001095716" value="Congo, Democratic Republic of the">Congo, Democratic Republic of the</option> <option data-id="35001095717" value="Congo, Republic of the">Congo, Republic of the</option> <option data-id="35001095718" value="Costa Rica">Costa Rica</option> <option data-id="35001095719" value="Croatia">Croatia</option> <option data-id="35001095720" value="Cuba">Cuba</option> <option data-id="35001095721" value="Cyprus">Cyprus</option> <option data-id="35001095722" value="Czech Republic">Czech Republic</option> <option data-id="35001095723" value="Denmark">Denmark</option> <option data-id="35001095724" value="Djibouti">Djibouti</option> <option data-id="35001095725" value="Dominica">Dominica</option> <option data-id="35001095726" value="Dominican Republic">Dominican Republic</option> <option data-id="35001095727" value="Ecuador">Ecuador</option> <option data-id="35001095728" value="Egypt">Egypt</option> <option data-id="35001095729" value="El Salvador">El Salvador</option> <option data-id="35001095730" value="Equatorial Guinea">Equatorial Guinea</option> <option data-id="35001095731" value="Eritrea">Eritrea</option> <option data-id="35001095732" value="Estonia">Estonia</option> <option data-id="35001095733" value="Eswatini">Eswatini</option> <option data-id="35001095734" value="Ethiopia">Ethiopia</option> <option data-id="35001095735" value="Fiji">Fiji</option> <option data-id="35001095736" value="Finland">Finland</option> <option data-id="35001095737" value="France">France</option> <option data-id="35001095738" value="Gabon">Gabon</option> <option data-id="35001095739" value="Gambia">Gambia</option> <option data-id="35001095740" value="Georgia">Georgia</option> <option data-id="35001095741" value="Germany">Germany</option> <option data-id="35001095742" value="Ghana">Ghana</option> <option data-id="35001095743" value="Greece">Greece</option> <option data-id="35001095744" value="Grenada">Grenada</option> <option data-id="35001095745" value="Guatemala">Guatemala</option> <option data-id="35001095746" value="Guinea">Guinea</option> <option data-id="35001095747" value="Guinea-Bissau">Guinea-Bissau</option> <option data-id="35001095748" value="Guyana">Guyana</option> <option data-id="35001095749" value="Haiti">Haiti</option> <option data-id="35001095750" value="Honduras">Honduras</option> <option data-id="35001095751" value="Hungary">Hungary</option> <option data-id="35001095752" value="Iceland">Iceland</option> <option data-id="35001095753" value="India">India</option> <option data-id="35001095754" value="Indonesia">Indonesia</option> <option data-id="35001095755" value="Iran">Iran</option> <option data-id="35001095756" value="Iraq">Iraq</option> <option data-id="35001095757" value="Ireland">Ireland</option> <option data-id="35001095758" value="Israel">Israel</option> <option data-id="35001095759" value="Italy">Italy</option> <option data-id="35001095760" value="Jamaica">Jamaica</option> <option data-id="35001095761" value="Japan">Japan</option> <option data-id="35001095762" value="Jordan">Jordan</option> <option data-id="35001095763" value="Kazakhstan">Kazakhstan</option> <option data-id="35001095764" value="Kenya">Kenya</option> <option data-id="35001095765" value="Kiribati">Kiribati</option> <option data-id="35001095766" value="Korea, North">Korea, North</option> <option data-id="35001095767" value="Korea, South">Korea, South</option> <option data-id="35001095768" value="Kosovo">Kosovo</option> <option data-id="35001095769" value="Kuwait">Kuwait</option> <option data-id="35001095770" value="Kyrgyzstan">Kyrgyzstan</option> <option data-id="35001095771" value="Laos">Laos</option> <option data-id="35001095772" value="Latvia">Latvia</option> <option data-id="35001095773" value="Lebanon">Lebanon</option> <option data-id="35001095774" value="Lesotho">Lesotho</option> <option data-id="35001095775" value="Liberia">Liberia</option> <option data-id="35001095776" value="Libya">Libya</option> <option data-id="35001095777" value="Liechtenstein">Liechtenstein</option> <option data-id="35001095778" value="Lithuania">Lithuania</option> <option data-id="35001095779" value="Luxembourg">Luxembourg</option> <option data-id="35001095780" value="Madagascar">Madagascar</option> <option data-id="35001095781" value="Malawi">Malawi</option> <option data-id="35001095782" value="Malaysia">Malaysia</option> <option data-id="35001095783" value="Maldives">Maldives</option> <option data-id="35001095784" value="Mali">Mali</option> <option data-id="35001095785" value="Malta">Malta</option> <option data-id="35001095786" value="Marshall Islands">Marshall Islands</option> <option data-id="35001095787" value="Mauritania">Mauritania</option> <option data-id="35001095788" value="Mauritius">Mauritius</option> <option data-id="35001095789" value="Mexico">Mexico</option> <option data-id="35001095790" value="Micronesia">Micronesia</option> <option data-id="35001095791" value="Moldova">Moldova</option> <option data-id="35001095792" value="Monaco">Monaco</option> <option data-id="35001095793" value="Mongolia">Mongolia</option> <option data-id="35001095794" value="Montenegro">Montenegro</option> <option data-id="35001095795" value="Morocco">Morocco</option> <option data-id="35001095796" value="Mozambique">Mozambique</option> <option data-id="35001095797" value="Myanmar">Myanmar</option> <option data-id="35001095798" value="Namibia">Namibia</option> <option data-id="35001095799" value="Nauru">Nauru</option> <option data-id="35001095800" value="Nepal">Nepal</option> <option data-id="35001095801" value="Netherlands">Netherlands</option> <option data-id="35001095802" value="New Zealand">New Zealand</option> <option data-id="35001095803" value="Nicaragua">Nicaragua</option> <option data-id="35001095804" value="Niger">Niger</option> <option data-id="35001095805" value="Nigeria">Nigeria</option> <option data-id="35001095806" value="North Macedonia">North Macedonia</option> <option data-id="35001095807" value="Norway">Norway</option> <option data-id="35001095808" value="Oman">Oman</option> <option data-id="35001095809" value="Pakistan">Pakistan</option> <option data-id="35001095810" value="Palau">Palau</option> <option data-id="35001095811" value="Palestine">Palestine</option> <option data-id="35001095812" value="Panama">Panama</option> <option data-id="35001095813" value="Papua New Guinea">Papua New Guinea</option> <option data-id="35001095814" value="Paraguay">Paraguay</option> <option data-id="35001095815" value="Peru">Peru</option> <option data-id="35001095816" value="Philippines">Philippines</option> <option data-id="35001095817" value="Poland">Poland</option> <option data-id="35001095818" value="Portugal">Portugal</option> <option data-id="35001095819" value="Qatar">Qatar</option> <option data-id="35001095820" value="Romania">Romania</option> <option data-id="35001095821" value="Russia">Russia</option> <option data-id="35001095822" value="Rwanda">Rwanda</option> <option data-id="35001095823" value="Saint Kitts and Nevis">Saint Kitts and Nevis</option> <option data-id="35001095824" value="Saint Lucia">Saint Lucia</option> <option data-id="35001095825" value="Saint Vincent and the Grenadines">Saint Vincent and the Grenadines</option> <option data-id="35001095826" value="Samoa">Samoa</option> <option data-id="35001095827" value="San Marino">San Marino</option> <option data-id="35001095828" value="Sao Tome and Principe">Sao Tome and Principe</option> <option data-id="35001095829" value="Saudi Arabia">Saudi Arabia</option> <option data-id="35001095830" value="Senegal">Senegal</option> <option data-id="35001095831" value="Serbia">Serbia</option> <option data-id="35001095832" value="Seychelles">Seychelles</option> <option data-id="35001095833" value="Sierra Leone">Sierra Leone</option> <option data-id="35001095834" value="Singapore">Singapore</option> <option data-id="35001095835" value="Slovakia">Slovakia</option> <option data-id="35001095836" value="Slovenia">Slovenia</option> <option data-id="35001095837" value="Solomon Islands">Solomon Islands</option> <option data-id="35001095838" value="Somalia">Somalia</option> <option data-id="35001095839" value="South Africa">South Africa</option> <option data-id="35001095840" value="South Sudan">South Sudan</option> <option data-id="35001095841" value="Spain">Spain</option> <option data-id="35001095842" value="Sri Lanka">Sri Lanka</option> <option data-id="35001095843" value="Sudan">Sudan</option> <option data-id="35001095844" value="Suriname">Suriname</option> <option data-id="35001095845" value="Sweden">Sweden</option> <option data-id="35001095846" value="Switzerland">Switzerland</option> <option data-id="35001095847" value="Syria">Syria</option> <option data-id="35001095848" value="Taiwan">Taiwan</option> <option data-id="35001095849" value="Tajikistan">Tajikistan</option> <option data-id="35001095850" value="Tanzania">Tanzania</option> <option data-id="35001095851" value="Thailand">Thailand</option> <option data-id="35001095852" value="Timor-Leste">Timor-Leste</option> <option data-id="35001095853" value="Togo">Togo</option> <option data-id="35001095854" value="Tonga">Tonga</option> <option data-id="35001095855" value="Trinidad and Tobago">Trinidad and Tobago</option> <option data-id="35001095856" value="Tunisia">Tunisia</option> <option data-id="35001095857" value="Turkey">Turkey</option> <option data-id="35001095858" value="Turkmenistan">Turkmenistan</option> <option data-id="35001095859" value="Tuvalu">Tuvalu</option> <option data-id="35001095860" value="Uganda">Uganda</option> <option data-id="35001095861" value="Ukraine">Ukraine</option> <option data-id="35001095862" value="United Arab Emirates">United Arab Emirates</option> <option data-id="35001095863" value="United Kingdom">United Kingdom</option> <option data-id="35001095864" value="United States">United States</option> <option data-id="35001095865" value="Uruguay">Uruguay</option> <option data-id="35001095866" value="Uzbekistan">Uzbekistan</option> <option data-id="35001095867" value="Vanuatu">Vanuatu</option> <option data-id="35001095868" value="Vatican City">Vatican City</option> <option data-id="35001095869" value="Venezuela">Venezuela</option> <option data-id="35001095870" value="Vietnam">Vietnam</option> <option data-id="35001095871" value="Yemen">Yemen</option> <option data-id="35001095872" value="Zambia">Zambia</option> <option data-id="35001095873" value="Zimbabwe">Zimbabwe</option></select> </div> </div> <div class="control-group ticket_section"> <label class=" control-label cf_phone_number_767862-label " for="helpdesk_ticket_cf_phone_number_767862">Phone Number</label> <div class="controls "> <input class=" text section_field span12" placeholder="" type="text" name="helpdesk_ticket[custom_field][cf_phone_number_767862]" id="helpdesk_ticket_custom_field_cf_phone_number_767862" /> </div> </div> <div class="control-group ticket_section"> <label class=" required control-label cf_productservice_767862-label " for="helpdesk_ticket_cf_productservice_767862">Product/Service Interest</label> <div class="controls "> <select class=" required dropdown_blank section_field" data-placeholder="..." name="helpdesk_ticket[custom_field][cf_productservice_767862]" id="helpdesk_ticket_custom_field_cf_productservice_767862"><option value="">...</option> <option data-id="35001082635" value="Advantis Platform | Brain & Prostate">Advantis Platform | Brain & Prostate</option> <option data-id="35000677602" value="Advantis Platform | Brain (Brainance MD)">Advantis Platform | Brain (Brainance MD)</option> <option data-id="35001065978" value="Advantis Platform | Prostate">Advantis Platform | Prostate</option> <option data-id="35001082554" value="PACS interconnection">PACS interconnection</option> <option data-id="35001065979" value="Advantis Academy">Advantis Academy</option> <option data-id="35000677604" value="Website">Website</option> <option data-id="35001082555" value="User Guide / Instructions for Use & Documentation">User Guide / Instructions for Use & Documentation</option> <option data-id="35001082556" value="Quality Management System">Quality Management System</option> <option data-id="35000677605" value="Other">Other</option></select> </div> </div>
<div class="control-group ticket_section"> <label class=" required control-label cf_occupation_767862-label " for="helpdesk_ticket_cf_occupation_767862">Occupation</label> <div class="controls "> <select class=" required dropdown_blank section_field" data-placeholder="..." name="helpdesk_ticket[custom_field][cf_occupation_767862]" id="helpdesk_ticket_custom_field_cf_occupation_767862"><option value="">...</option> <option data-id="35000677596" value="radiologist">radiologist</option> <option data-id="35001082549" value="neuroradiologist">neuroradiologist</option> <option data-id="35001082550" value="neurosurgeon">neurosurgeon</option> <option data-id="35001082551" value="urologist">urologist</option> <option data-id="35000677597" value="MRI specialist">MRI specialist</option> <option data-id="35001082552" value="researcher">researcher</option> <option data-id="35000677598" value="healthcare IT">healthcare IT</option> <option data-id="35000677599" value="manager/owner">manager/owner</option> <option data-id="35001082553" value="distributor">distributor</option> <option data-id="35000677600" value="student">student</option> <option data-id="35000677601" value="other">other</option></select> </div> </div> <div class="control-group ticket_section"> <label class=" required control-label cf_company_institution_767862-label " for="helpdesk_ticket_cf_company_institution_767862">Company / Institution</label> <div class="controls "> <input class=" required text section_field span12" placeholder="" type="text" name="helpdesk_ticket[custom_field][cf_company_institution_767862]" id="helpdesk_ticket_custom_field_cf_company_institution_767862" /> </div> </div> <div class="control-group ticket_section"> <label class=" control-label cf_country625518_767862-label " for="helpdesk_ticket_cf_country625518_767862">Country*</label> <div class="controls "> <select class=" dropdown_blank section_field" data-placeholder="..." name="helpdesk_ticket[custom_field][cf_country625518_767862]" id="helpdesk_ticket_custom_field_cf_country625518_767862"><option value="">...</option> <option data-id="35001095678" value="Afghanistan">Afghanistan</option> <option data-id="35001095679" value="Albania">Albania</option> <option data-id="35001095680" value="Algeria">Algeria</option> <option data-id="35001095681" value="Andorra">Andorra</option> <option data-id="35001095682" value="Angola">Angola</option> <option data-id="35001095683" value="Antigua and Barbuda">Antigua and Barbuda</option> <option data-id="35001095684" value="Argentina">Argentina</option> <option data-id="35001095685" value="Armenia">Armenia</option> <option data-id="35001095686" value="Australia">Australia</option> <option data-id="35001095687" value="Austria">Austria</option> <option data-id="35001095688" value="Azerbaijan">Azerbaijan</option> <option data-id="35001095689" value="Bahamas">Bahamas</option> <option data-id="35001095690" value="Bahrain">Bahrain</option> <option data-id="35001095691" value="Bangladesh">Bangladesh</option> <option data-id="35001095692" value="Barbados">Barbados</option> <option data-id="35001095693" value="Belarus">Belarus</option> <option data-id="35001095694" value="Belgium">Belgium</option> <option data-id="35001095695" value="Belize">Belize</option> <option data-id="35001095696" value="Benin">Benin</option> <option data-id="35001095697" value="Bhutan">Bhutan</option> <option data-id="35001095698" value="Bolivia">Bolivia</option> <option data-id="35001095699" value="Bosnia and Herzegovina">Bosnia and Herzegovina</option> <option data-id="35001095700" value="Botswana">Botswana</option> <option data-id="35001095701" value="Brazil">Brazil</option> <option data-id="35001095702" value="Brunei">Brunei</option> <option data-id="35001095703" value="Bulgaria">Bulgaria</option> <option data-id="35001095704" value="Burkina Faso">Burkina Faso</option> <option data-id="35001095705" value="Burundi">Burundi</option> <option data-id="35001095706" value="Cabo Verde">Cabo Verde</option> <option data-id="35001095707" value="Cambodia">Cambodia</option> <option data-id="35001095708" value="Cameroon">Cameroon</option> <option data-id="35001095709" value="Canada">Canada</option> <option data-id="35001095710" value="Central African Republic">Central African Republic</option> <option data-id="35001095711" value="Chad">Chad</option> <option data-id="35001095712" value="Chile">Chile</option> <option data-id="35001095713" value="China">China</option> <option data-id="35001095714" value="Colombia">Colombia</option> <option data-id="35001095715" value="Comoros">Comoros</option> <option data-id="35001095716" value="Congo, Democratic Republic of the">Congo, Democratic Republic of the</option> <option data-id="35001095717" value="Congo, Republic of the">Congo, Republic of the</option> <option data-id="35001095718" value="Costa Rica">Costa Rica</option> <option data-id="35001095719" value="Croatia">Croatia</option> <option data-id="35001095720" value="Cuba">Cuba</option> <option data-id="35001095721" value="Cyprus">Cyprus</option> <option data-id="35001095722" value="Czech Republic">Czech Republic</option> <option data-id="35001095723" value="Denmark">Denmark</option> <option data-id="35001095724" value="Djibouti">Djibouti</option> <option data-id="35001095725" value="Dominica">Dominica</option> <option data-id="35001095726" value="Dominican Republic">Dominican Republic</option> <option data-id="35001095727" value="Ecuador">Ecuador</option> <option data-id="35001095728" value="Egypt">Egypt</option> <option data-id="35001095729" value="El Salvador">El Salvador</option> <option data-id="35001095730" value="Equatorial Guinea">Equatorial Guinea</option> <option data-id="35001095731" value="Eritrea">Eritrea</option> <option data-id="35001095732" value="Estonia">Estonia</option> <option data-id="35001095733" value="Eswatini">Eswatini</option> <option data-id="35001095734" value="Ethiopia">Ethiopia</option> <option data-id="35001095735" value="Fiji">Fiji</option> <option data-id="35001095736" value="Finland">Finland</option> <option data-id="35001095737" value="France">France</option> <option data-id="35001095738" value="Gabon">Gabon</option> <option data-id="35001095739" value="Gambia">Gambia</option> <option data-id="35001095740" value="Georgia">Georgia</option> <option data-id="35001095741" value="Germany">Germany</option> <option data-id="35001095742" value="Ghana">Ghana</option> <option data-id="35001095743" value="Greece">Greece</option> <option data-id="35001095744" value="Grenada">Grenada</option> <option data-id="35001095745" value="Guatemala">Guatemala</option> <option data-id="35001095746" value="Guinea">Guinea</option> <option data-id="35001095747" value="Guinea-Bissau">Guinea-Bissau</option> <option data-id="35001095748" value="Guyana">Guyana</option> <option data-id="35001095749" value="Haiti">Haiti</option> <option data-id="35001095750" value="Honduras">Honduras</option> <option data-id="35001095751" value="Hungary">Hungary</option> <option data-id="35001095752" value="Iceland">Iceland</option> <option data-id="35001095753" value="India">India</option> <option data-id="35001095754" value="Indonesia">Indonesia</option> <option data-id="35001095755" value="Iran">Iran</option> <option data-id="35001095756" value="Iraq">Iraq</option> <option data-id="35001095757" value="Ireland">Ireland</option> <option data-id="35001095758" value="Israel">Israel</option> <option data-id="35001095759" value="Italy">Italy</option> <option data-id="35001095760" value="Jamaica">Jamaica</option> <option data-id="35001095761" value="Japan">Japan</option> <option data-id="35001095762" value="Jordan">Jordan</option> <option data-id="35001095763" value="Kazakhstan">Kazakhstan</option> <option data-id="35001095764" value="Kenya">Kenya</option> <option data-id="35001095765" value="Kiribati">Kiribati</option> <option data-id="35001095766" value="Korea, North">Korea, North</option> <option data-id="35001095767" value="Korea, South">Korea, South</option> <option data-id="35001095768" value="Kosovo">Kosovo</option> <option data-id="35001095769" value="Kuwait">Kuwait</option> <option data-id="35001095770" value="Kyrgyzstan">Kyrgyzstan</option> <option data-id="35001095771" value="Laos">Laos</option> <option data-id="35001095772" value="Latvia">Latvia</option> <option data-id="35001095773" value="Lebanon">Lebanon</option> <option data-id="35001095774" value="Lesotho">Lesotho</option> <option data-id="35001095775" value="Liberia">Liberia</option> <option data-id="35001095776" value="Libya">Libya</option> <option data-id="35001095777" value="Liechtenstein">Liechtenstein</option> <option data-id="35001095778" value="Lithuania">Lithuania</option> <option data-id="35001095779" value="Luxembourg">Luxembourg</option> <option data-id="35001095780" value="Madagascar">Madagascar</option> <option data-id="35001095781" value="Malawi">Malawi</option> <option data-id="35001095782" value="Malaysia">Malaysia</option> <option data-id="35001095783" value="Maldives">Maldives</option> <option data-id="35001095784" value="Mali">Mali</option> <option data-id="35001095785" value="Malta">Malta</option> <option data-id="35001095786" value="Marshall Islands">Marshall Islands</option> <option data-id="35001095787" value="Mauritania">Mauritania</option> <option data-id="35001095788" value="Mauritius">Mauritius</option> <option data-id="35001095789" value="Mexico">Mexico</option> <option data-id="35001095790" value="Micronesia">Micronesia</option> <option data-id="35001095791" value="Moldova">Moldova</option> <option data-id="35001095792" value="Monaco">Monaco</option> <option data-id="35001095793" value="Mongolia">Mongolia</option> <option data-id="35001095794" value="Montenegro">Montenegro</option> <option data-id="35001095795" value="Morocco">Morocco</option> <option data-id="35001095796" value="Mozambique">Mozambique</option> <option data-id="35001095797" value="Myanmar">Myanmar</option> <option data-id="35001095798" value="Namibia">Namibia</option> <option data-id="35001095799" value="Nauru">Nauru</option> <option data-id="35001095800" value="Nepal">Nepal</option> <option data-id="35001095801" value="Netherlands">Netherlands</option> <option data-id="35001095802" value="New Zealand">New Zealand</option> <option data-id="35001095803" value="Nicaragua">Nicaragua</option> <option data-id="35001095804" value="Niger">Niger</option> <option data-id="35001095805" value="Nigeria">Nigeria</option> <option data-id="35001095806" value="North Macedonia">North Macedonia</option> <option data-id="35001095807" value="Norway">Norway</option> <option data-id="35001095808" value="Oman">Oman</option> <option data-id="35001095809" value="Pakistan">Pakistan</option> <option data-id="35001095810" value="Palau">Palau</option> <option data-id="35001095811" value="Palestine">Palestine</option> <option data-id="35001095812" value="Panama">Panama</option> <option data-id="35001095813" value="Papua New Guinea">Papua New Guinea</option> <option data-id="35001095814" value="Paraguay">Paraguay</option> <option data-id="35001095815" value="Peru">Peru</option> <option data-id="35001095816" value="Philippines">Philippines</option> <option data-id="35001095817" value="Poland">Poland</option> <option data-id="35001095818" value="Portugal">Portugal</option> <option data-id="35001095819" value="Qatar">Qatar</option> <option data-id="35001095820" value="Romania">Romania</option> <option data-id="35001095821" value="Russia">Russia</option> <option data-id="35001095822" value="Rwanda">Rwanda</option> <option data-id="35001095823" value="Saint Kitts and Nevis">Saint Kitts and Nevis</option> <option data-id="35001095824" value="Saint Lucia">Saint Lucia</option> <option data-id="35001095825" value="Saint Vincent and the Grenadines">Saint Vincent and the Grenadines</option> <option data-id="35001095826" value="Samoa">Samoa</option> <option data-id="35001095827" value="San Marino">San Marino</option> <option data-id="35001095828" value="Sao Tome and Principe">Sao Tome and Principe</option> <option data-id="35001095829" value="Saudi Arabia">Saudi Arabia</option> <option data-id="35001095830" value="Senegal">Senegal</option> <option data-id="35001095831" value="Serbia">Serbia</option> <option data-id="35001095832" value="Seychelles">Seychelles</option> <option data-id="35001095833" value="Sierra Leone">Sierra Leone</option> <option data-id="35001095834" value="Singapore">Singapore</option> <option data-id="35001095835" value="Slovakia">Slovakia</option> <option data-id="35001095836" value="Slovenia">Slovenia</option> <option data-id="35001095837" value="Solomon Islands">Solomon Islands</option> <option data-id="35001095838" value="Somalia">Somalia</option> <option data-id="35001095839" value="South Africa">South Africa</option> <option data-id="35001095840" value="South Sudan">South Sudan</option> <option data-id="35001095841" value="Spain">Spain</option> <option data-id="35001095842" value="Sri Lanka">Sri Lanka</option> <option data-id="35001095843" value="Sudan">Sudan</option> <option data-id="35001095844" value="Suriname">Suriname</option> <option data-id="35001095845" value="Sweden">Sweden</option> <option data-id="35001095846" value="Switzerland">Switzerland</option> <option data-id="35001095847" value="Syria">Syria</option> <option data-id="35001095848" value="Taiwan">Taiwan</option> <option data-id="35001095849" value="Tajikistan">Tajikistan</option> <option data-id="35001095850" value="Tanzania">Tanzania</option> <option data-id="35001095851" value="Thailand">Thailand</option> <option data-id="35001095852" value="Timor-Leste">Timor-Leste</option> <option data-id="35001095853" value="Togo">Togo</option> <option data-id="35001095854" value="Tonga">Tonga</option> <option data-id="35001095855" value="Trinidad and Tobago">Trinidad and Tobago</option> <option data-id="35001095856" value="Tunisia">Tunisia</option> <option data-id="35001095857" value="Turkey">Turkey</option> <option data-id="35001095858" value="Turkmenistan">Turkmenistan</option> <option data-id="35001095859" value="Tuvalu">Tuvalu</option> <option data-id="35001095860" value="Uganda">Uganda</option> <option data-id="35001095861" value="Ukraine">Ukraine</option> <option data-id="35001095862" value="United Arab Emirates">United Arab Emirates</option> <option data-id="35001095863" value="United Kingdom">United Kingdom</option> <option data-id="35001095864" value="United States">United States</option> <option data-id="35001095865" value="Uruguay">Uruguay</option> <option data-id="35001095866" value="Uzbekistan">Uzbekistan</option> <option data-id="35001095867" value="Vanuatu">Vanuatu</option> <option data-id="35001095868" value="Vatican City">Vatican City</option> <option data-id="35001095869" value="Venezuela">Venezuela</option> <option data-id="35001095870" value="Vietnam">Vietnam</option> <option data-id="35001095871" value="Yemen">Yemen</option> <option data-id="35001095872" value="Zambia">Zambia</option> <option data-id="35001095873" value="Zimbabwe">Zimbabwe</option></select> </div> </div> <div class="control-group ticket_section"> <label class=" control-label cf_phone_number_767862-label " for="helpdesk_ticket_cf_phone_number_767862">Phone Number</label> <div class="controls "> <input class=" text section_field span12" placeholder="" type="text" name="helpdesk_ticket[custom_field][cf_phone_number_767862]" id="helpdesk_ticket_custom_field_cf_phone_number_767862" /> </div> </div> <div class="control-group ticket_section"> <label class=" required control-label cf_productservice_767862-label " for="helpdesk_ticket_cf_productservice_767862">Product/Service Interest</label> <div class="controls "> <select class=" required dropdown_blank section_field" data-placeholder="..." name="helpdesk_ticket[custom_field][cf_productservice_767862]" id="helpdesk_ticket_custom_field_cf_productservice_767862"><option value="">...</option> <option data-id="35001082635" value="Advantis Platform | Brain & Prostate">Advantis Platform | Brain & Prostate</option> <option data-id="35000677602" value="Advantis Platform | Brain (Brainance MD)">Advantis Platform | Brain (Brainance MD)</option> <option data-id="35001065978" value="Advantis Platform | Prostate">Advantis Platform | Prostate</option> <option data-id="35001082554" value="PACS interconnection">PACS interconnection</option> <option data-id="35001065979" value="Advantis Academy">Advantis Academy</option> <option data-id="35000677604" value="Website">Website</option> <option data-id="35001082555" value="User Guide / Instructions for Use & Documentation">User Guide / Instructions for Use & Documentation</option> <option data-id="35001082556" value="Quality Management System">Quality Management System</option> <option data-id="35000677605" value="Other">Other</option></select> </div> </div>
<div class="control-group ticket_section"> <label class=" required control-label cf_occupation_767862-label " for="helpdesk_ticket_cf_occupation_767862">Occupation</label> <div class="controls "> <select class=" required dropdown_blank section_field" data-placeholder="..." name="helpdesk_ticket[custom_field][cf_occupation_767862]" id="helpdesk_ticket_custom_field_cf_occupation_767862"><option value="">...</option> <option data-id="35000677596" value="radiologist">radiologist</option> <option data-id="35001082549" value="neuroradiologist">neuroradiologist</option> <option data-id="35001082550" value="neurosurgeon">neurosurgeon</option> <option data-id="35001082551" value="urologist">urologist</option> <option data-id="35000677597" value="MRI specialist">MRI specialist</option> <option data-id="35001082552" value="researcher">researcher</option> <option data-id="35000677598" value="healthcare IT">healthcare IT</option> <option data-id="35000677599" value="manager/owner">manager/owner</option> <option data-id="35001082553" value="distributor">distributor</option> <option data-id="35000677600" value="student">student</option> <option data-id="35000677601" value="other">other</option></select> </div> </div> <div class="control-group ticket_section"> <label class=" required control-label cf_company_institution_767862-label " for="helpdesk_ticket_cf_company_institution_767862">Company / Institution</label> <div class="controls "> <input class=" required text section_field span12" placeholder="" type="text" name="helpdesk_ticket[custom_field][cf_company_institution_767862]" id="helpdesk_ticket_custom_field_cf_company_institution_767862" /> </div> </div> <div class="control-group ticket_section"> <label class=" control-label cf_country625518_767862-label " for="helpdesk_ticket_cf_country625518_767862">Country*</label> <div class="controls "> <select class=" dropdown_blank section_field" data-placeholder="..." name="helpdesk_ticket[custom_field][cf_country625518_767862]" id="helpdesk_ticket_custom_field_cf_country625518_767862"><option value="">...</option> <option data-id="35001095678" value="Afghanistan">Afghanistan</option> <option data-id="35001095679" value="Albania">Albania</option> <option data-id="35001095680" value="Algeria">Algeria</option> <option data-id="35001095681" value="Andorra">Andorra</option> <option data-id="35001095682" value="Angola">Angola</option> <option data-id="35001095683" value="Antigua and Barbuda">Antigua and Barbuda</option> <option data-id="35001095684" value="Argentina">Argentina</option> <option data-id="35001095685" value="Armenia">Armenia</option> <option data-id="35001095686" value="Australia">Australia</option> <option data-id="35001095687" value="Austria">Austria</option> <option data-id="35001095688" value="Azerbaijan">Azerbaijan</option> <option data-id="35001095689" value="Bahamas">Bahamas</option> <option data-id="35001095690" value="Bahrain">Bahrain</option> <option data-id="35001095691" value="Bangladesh">Bangladesh</option> <option data-id="35001095692" value="Barbados">Barbados</option> <option data-id="35001095693" value="Belarus">Belarus</option> <option data-id="35001095694" value="Belgium">Belgium</option> <option data-id="35001095695" value="Belize">Belize</option> <option data-id="35001095696" value="Benin">Benin</option> <option data-id="35001095697" value="Bhutan">Bhutan</option> <option data-id="35001095698" value="Bolivia">Bolivia</option> <option data-id="35001095699" value="Bosnia and Herzegovina">Bosnia and Herzegovina</option> <option data-id="35001095700" value="Botswana">Botswana</option> <option data-id="35001095701" value="Brazil">Brazil</option> <option data-id="35001095702" value="Brunei">Brunei</option> <option data-id="35001095703" value="Bulgaria">Bulgaria</option> <option data-id="35001095704" value="Burkina Faso">Burkina Faso</option> <option data-id="35001095705" value="Burundi">Burundi</option> <option data-id="35001095706" value="Cabo Verde">Cabo Verde</option> <option data-id="35001095707" value="Cambodia">Cambodia</option> <option data-id="35001095708" value="Cameroon">Cameroon</option> <option data-id="35001095709" value="Canada">Canada</option> <option data-id="35001095710" value="Central African Republic">Central African Republic</option> <option data-id="35001095711" value="Chad">Chad</option> <option data-id="35001095712" value="Chile">Chile</option> <option data-id="35001095713" value="China">China</option> <option data-id="35001095714" value="Colombia">Colombia</option> <option data-id="35001095715" value="Comoros">Comoros</option> <option data-id="35001095716" value="Congo, Democratic Republic of the">Congo, Democratic Republic of the</option> <option data-id="35001095717" value="Congo, Republic of the">Congo, Republic of the</option> <option data-id="35001095718" value="Costa Rica">Costa Rica</option> <option data-id="35001095719" value="Croatia">Croatia</option> <option data-id="35001095720" value="Cuba">Cuba</option> <option data-id="35001095721" value="Cyprus">Cyprus</option> <option data-id="35001095722" value="Czech Republic">Czech Republic</option> <option data-id="35001095723" value="Denmark">Denmark</option> <option data-id="35001095724" value="Djibouti">Djibouti</option> <option data-id="35001095725" value="Dominica">Dominica</option> <option data-id="35001095726" value="Dominican Republic">Dominican Republic</option> <option data-id="35001095727" value="Ecuador">Ecuador</option> <option data-id="35001095728" value="Egypt">Egypt</option> <option data-id="35001095729" value="El Salvador">El Salvador</option> <option data-id="35001095730" value="Equatorial Guinea">Equatorial Guinea</option> <option data-id="35001095731" value="Eritrea">Eritrea</option> <option data-id="35001095732" value="Estonia">Estonia</option> <option data-id="35001095733" value="Eswatini">Eswatini</option> <option data-id="35001095734" value="Ethiopia">Ethiopia</option> <option data-id="35001095735" value="Fiji">Fiji</option> <option data-id="35001095736" value="Finland">Finland</option> <option data-id="35001095737" value="France">France</option> <option data-id="35001095738" value="Gabon">Gabon</option> <option data-id="35001095739" value="Gambia">Gambia</option> <option data-id="35001095740" value="Georgia">Georgia</option> <option data-id="35001095741" value="Germany">Germany</option> <option data-id="35001095742" value="Ghana">Ghana</option> <option data-id="35001095743" value="Greece">Greece</option> <option data-id="35001095744" value="Grenada">Grenada</option> <option data-id="35001095745" value="Guatemala">Guatemala</option> <option data-id="35001095746" value="Guinea">Guinea</option> <option data-id="35001095747" value="Guinea-Bissau">Guinea-Bissau</option> <option data-id="35001095748" value="Guyana">Guyana</option> <option data-id="35001095749" value="Haiti">Haiti</option> <option data-id="35001095750" value="Honduras">Honduras</option> <option data-id="35001095751" value="Hungary">Hungary</option> <option data-id="35001095752" value="Iceland">Iceland</option> <option data-id="35001095753" value="India">India</option> <option data-id="35001095754" value="Indonesia">Indonesia</option> <option data-id="35001095755" value="Iran">Iran</option> <option data-id="35001095756" value="Iraq">Iraq</option> <option data-id="35001095757" value="Ireland">Ireland</option> <option data-id="35001095758" value="Israel">Israel</option> <option data-id="35001095759" value="Italy">Italy</option> <option data-id="35001095760" value="Jamaica">Jamaica</option> <option data-id="35001095761" value="Japan">Japan</option> <option data-id="35001095762" value="Jordan">Jordan</option> <option data-id="35001095763" value="Kazakhstan">Kazakhstan</option> <option data-id="35001095764" value="Kenya">Kenya</option> <option data-id="35001095765" value="Kiribati">Kiribati</option> <option data-id="35001095766" value="Korea, North">Korea, North</option> <option data-id="35001095767" value="Korea, South">Korea, South</option> <option data-id="35001095768" value="Kosovo">Kosovo</option> <option data-id="35001095769" value="Kuwait">Kuwait</option> <option data-id="35001095770" value="Kyrgyzstan">Kyrgyzstan</option> <option data-id="35001095771" value="Laos">Laos</option> <option data-id="35001095772" value="Latvia">Latvia</option> <option data-id="35001095773" value="Lebanon">Lebanon</option> <option data-id="35001095774" value="Lesotho">Lesotho</option> <option data-id="35001095775" value="Liberia">Liberia</option> <option data-id="35001095776" value="Libya">Libya</option> <option data-id="35001095777" value="Liechtenstein">Liechtenstein</option> <option data-id="35001095778" value="Lithuania">Lithuania</option> <option data-id="35001095779" value="Luxembourg">Luxembourg</option> <option data-id="35001095780" value="Madagascar">Madagascar</option> <option data-id="35001095781" value="Malawi">Malawi</option> <option data-id="35001095782" value="Malaysia">Malaysia</option> <option data-id="35001095783" value="Maldives">Maldives</option> <option data-id="35001095784" value="Mali">Mali</option> <option data-id="35001095785" value="Malta">Malta</option> <option data-id="35001095786" value="Marshall Islands">Marshall Islands</option> <option data-id="35001095787" value="Mauritania">Mauritania</option> <option data-id="35001095788" value="Mauritius">Mauritius</option> <option data-id="35001095789" value="Mexico">Mexico</option> <option data-id="35001095790" value="Micronesia">Micronesia</option> <option data-id="35001095791" value="Moldova">Moldova</option> <option data-id="35001095792" value="Monaco">Monaco</option> <option data-id="35001095793" value="Mongolia">Mongolia</option> <option data-id="35001095794" value="Montenegro">Montenegro</option> <option data-id="35001095795" value="Morocco">Morocco</option> <option data-id="35001095796" value="Mozambique">Mozambique</option> <option data-id="35001095797" value="Myanmar">Myanmar</option> <option data-id="35001095798" value="Namibia">Namibia</option> <option data-id="35001095799" value="Nauru">Nauru</option> <option data-id="35001095800" value="Nepal">Nepal</option> <option data-id="35001095801" value="Netherlands">Netherlands</option> <option data-id="35001095802" value="New Zealand">New Zealand</option> <option data-id="35001095803" value="Nicaragua">Nicaragua</option> <option data-id="35001095804" value="Niger">Niger</option> <option data-id="35001095805" value="Nigeria">Nigeria</option> <option data-id="35001095806" value="North Macedonia">North Macedonia</option> <option data-id="35001095807" value="Norway">Norway</option> <option data-id="35001095808" value="Oman">Oman</option> <option data-id="35001095809" value="Pakistan">Pakistan</option> <option data-id="35001095810" value="Palau">Palau</option> <option data-id="35001095811" value="Palestine">Palestine</option> <option data-id="35001095812" value="Panama">Panama</option> <option data-id="35001095813" value="Papua New Guinea">Papua New Guinea</option> <option data-id="35001095814" value="Paraguay">Paraguay</option> <option data-id="35001095815" value="Peru">Peru</option> <option data-id="35001095816" value="Philippines">Philippines</option> <option data-id="35001095817" value="Poland">Poland</option> <option data-id="35001095818" value="Portugal">Portugal</option> <option data-id="35001095819" value="Qatar">Qatar</option> <option data-id="35001095820" value="Romania">Romania</option> <option data-id="35001095821" value="Russia">Russia</option> <option data-id="35001095822" value="Rwanda">Rwanda</option> <option data-id="35001095823" value="Saint Kitts and Nevis">Saint Kitts and Nevis</option> <option data-id="35001095824" value="Saint Lucia">Saint Lucia</option> <option data-id="35001095825" value="Saint Vincent and the Grenadines">Saint Vincent and the Grenadines</option> <option data-id="35001095826" value="Samoa">Samoa</option> <option data-id="35001095827" value="San Marino">San Marino</option> <option data-id="35001095828" value="Sao Tome and Principe">Sao Tome and Principe</option> <option data-id="35001095829" value="Saudi Arabia">Saudi Arabia</option> <option data-id="35001095830" value="Senegal">Senegal</option> <option data-id="35001095831" value="Serbia">Serbia</option> <option data-id="35001095832" value="Seychelles">Seychelles</option> <option data-id="35001095833" value="Sierra Leone">Sierra Leone</option> <option data-id="35001095834" value="Singapore">Singapore</option> <option data-id="35001095835" value="Slovakia">Slovakia</option> <option data-id="35001095836" value="Slovenia">Slovenia</option> <option data-id="35001095837" value="Solomon Islands">Solomon Islands</option> <option data-id="35001095838" value="Somalia">Somalia</option> <option data-id="35001095839" value="South Africa">South Africa</option> <option data-id="35001095840" value="South Sudan">South Sudan</option> <option data-id="35001095841" value="Spain">Spain</option> <option data-id="35001095842" value="Sri Lanka">Sri Lanka</option> <option data-id="35001095843" value="Sudan">Sudan</option> <option data-id="35001095844" value="Suriname">Suriname</option> <option data-id="35001095845" value="Sweden">Sweden</option> <option data-id="35001095846" value="Switzerland">Switzerland</option> <option data-id="35001095847" value="Syria">Syria</option> <option data-id="35001095848" value="Taiwan">Taiwan</option> <option data-id="35001095849" value="Tajikistan">Tajikistan</option> <option data-id="35001095850" value="Tanzania">Tanzania</option> <option data-id="35001095851" value="Thailand">Thailand</option> <option data-id="35001095852" value="Timor-Leste">Timor-Leste</option> <option data-id="35001095853" value="Togo">Togo</option> <option data-id="35001095854" value="Tonga">Tonga</option> <option data-id="35001095855" value="Trinidad and Tobago">Trinidad and Tobago</option> <option data-id="35001095856" value="Tunisia">Tunisia</option> <option data-id="35001095857" value="Turkey">Turkey</option> <option data-id="35001095858" value="Turkmenistan">Turkmenistan</option> <option data-id="35001095859" value="Tuvalu">Tuvalu</option> <option data-id="35001095860" value="Uganda">Uganda</option> <option data-id="35001095861" value="Ukraine">Ukraine</option> <option data-id="35001095862" value="United Arab Emirates">United Arab Emirates</option> <option data-id="35001095863" value="United Kingdom">United Kingdom</option> <option data-id="35001095864" value="United States">United States</option> <option data-id="35001095865" value="Uruguay">Uruguay</option> <option data-id="35001095866" value="Uzbekistan">Uzbekistan</option> <option data-id="35001095867" value="Vanuatu">Vanuatu</option> <option data-id="35001095868" value="Vatican City">Vatican City</option> <option data-id="35001095869" value="Venezuela">Venezuela</option> <option data-id="35001095870" value="Vietnam">Vietnam</option> <option data-id="35001095871" value="Yemen">Yemen</option> <option data-id="35001095872" value="Zambia">Zambia</option> <option data-id="35001095873" value="Zimbabwe">Zimbabwe</option></select> </div> </div> <div class="control-group ticket_section"> <label class=" control-label cf_phone_number_767862-label " for="helpdesk_ticket_cf_phone_number_767862">Phone Number</label> <div class="controls "> <input class=" text section_field span12" placeholder="" type="text" name="helpdesk_ticket[custom_field][cf_phone_number_767862]" id="helpdesk_ticket_custom_field_cf_phone_number_767862" /> </div> </div> <div class="control-group ticket_section"> <label class=" required control-label cf_productservice_767862-label " for="helpdesk_ticket_cf_productservice_767862">Product/Service Interest</label> <div class="controls "> <select class=" required dropdown_blank section_field" data-placeholder="..." name="helpdesk_ticket[custom_field][cf_productservice_767862]" id="helpdesk_ticket_custom_field_cf_productservice_767862"><option value="">...</option> <option data-id="35001082635" value="Advantis Platform | Brain & Prostate">Advantis Platform | Brain & Prostate</option> <option data-id="35000677602" value="Advantis Platform | Brain (Brainance MD)">Advantis Platform | Brain (Brainance MD)</option> <option data-id="35001065978" value="Advantis Platform | Prostate">Advantis Platform | Prostate</option> <option data-id="35001082554" value="PACS interconnection">PACS interconnection</option> <option data-id="35001065979" value="Advantis Academy">Advantis Academy</option> <option data-id="35000677604" value="Website">Website</option> <option data-id="35001082555" value="User Guide / Instructions for Use & Documentation">User Guide / Instructions for Use & Documentation</option> <option data-id="35001082556" value="Quality Management System">Quality Management System</option> <option data-id="35000677605" value="Other">Other</option></select> </div> </div>
<div class="control-group ticket_section"> <label class=" required control-label cf_username_767862-label " for="helpdesk_ticket_cf_username_767862">Your Advantis Platform Username</label> <div class="controls "> <input class=" required text section_field span12" placeholder="" type="text" name="helpdesk_ticket[custom_field][cf_username_767862]" id="helpdesk_ticket_custom_field_cf_username_767862" /> </div> </div> <div class="control-group ticket_section"> <label class=" required control-label cf_orgname_on_brainance_767862-label " for="helpdesk_ticket_cf_orgname_on_brainance_767862">Orgname on Advantis Platform</label> <div class="controls "> <input class=" required text section_field span12" placeholder="" type="text" name="helpdesk_ticket[custom_field][cf_orgname_on_brainance_767862]" id="helpdesk_ticket_custom_field_cf_orgname_on_brainance_767862" /> </div> </div> <div class="control-group ticket_section"> <label class=" control-label cf_format_767862-label " for="helpdesk_ticket_cf_format_767862">Format</label> <div class="controls "> <select class=" dropdown_blank section_field" data-placeholder="..." name="helpdesk_ticket[custom_field][cf_format_767862]" id="helpdesk_ticket_custom_field_cf_format_767862"><option value="">...</option> <option data-id="35000717170" value="Digital Copy">Digital Copy</option> <option data-id="35000717171" value="Hard Copy">Hard Copy</option></select> </div> </div> <div class="control-group ticket_section"> <label class=" control-label cf_country625518_767862-label " for="helpdesk_ticket_cf_country625518_767862">Country*</label> <div class="controls "> <select class=" dropdown_blank section_field" data-placeholder="..." name="helpdesk_ticket[custom_field][cf_country625518_767862]" id="helpdesk_ticket_custom_field_cf_country625518_767862"><option value="">...</option> <option data-id="35001095678" value="Afghanistan">Afghanistan</option> <option data-id="35001095679" value="Albania">Albania</option> <option data-id="35001095680" value="Algeria">Algeria</option> <option data-id="35001095681" value="Andorra">Andorra</option> <option data-id="35001095682" value="Angola">Angola</option> <option data-id="35001095683" value="Antigua and Barbuda">Antigua and Barbuda</option> <option data-id="35001095684" value="Argentina">Argentina</option> <option data-id="35001095685" value="Armenia">Armenia</option> <option data-id="35001095686" value="Australia">Australia</option> <option data-id="35001095687" value="Austria">Austria</option> <option data-id="35001095688" value="Azerbaijan">Azerbaijan</option> <option data-id="35001095689" value="Bahamas">Bahamas</option> <option data-id="35001095690" value="Bahrain">Bahrain</option> <option data-id="35001095691" value="Bangladesh">Bangladesh</option> <option data-id="35001095692" value="Barbados">Barbados</option> <option data-id="35001095693" value="Belarus">Belarus</option> <option data-id="35001095694" value="Belgium">Belgium</option> <option data-id="35001095695" value="Belize">Belize</option> <option data-id="35001095696" value="Benin">Benin</option> <option data-id="35001095697" value="Bhutan">Bhutan</option> <option data-id="35001095698" value="Bolivia">Bolivia</option> <option data-id="35001095699" value="Bosnia and Herzegovina">Bosnia and Herzegovina</option> <option data-id="35001095700" value="Botswana">Botswana</option> <option data-id="35001095701" value="Brazil">Brazil</option> <option data-id="35001095702" value="Brunei">Brunei</option> <option data-id="35001095703" value="Bulgaria">Bulgaria</option> <option data-id="35001095704" value="Burkina Faso">Burkina Faso</option> <option data-id="35001095705" value="Burundi">Burundi</option> <option data-id="35001095706" value="Cabo Verde">Cabo Verde</option> <option data-id="35001095707" value="Cambodia">Cambodia</option> <option data-id="35001095708" value="Cameroon">Cameroon</option> <option data-id="35001095709" value="Canada">Canada</option> <option data-id="35001095710" value="Central African Republic">Central African Republic</option> <option data-id="35001095711" value="Chad">Chad</option> <option data-id="35001095712" value="Chile">Chile</option> <option data-id="35001095713" value="China">China</option> <option data-id="35001095714" value="Colombia">Colombia</option> <option data-id="35001095715" value="Comoros">Comoros</option> <option data-id="35001095716" value="Congo, Democratic Republic of the">Congo, Democratic Republic of the</option> <option data-id="35001095717" value="Congo, Republic of the">Congo, Republic of the</option> <option data-id="35001095718" value="Costa Rica">Costa Rica</option> <option data-id="35001095719" value="Croatia">Croatia</option> <option data-id="35001095720" value="Cuba">Cuba</option> <option data-id="35001095721" value="Cyprus">Cyprus</option> <option data-id="35001095722" value="Czech Republic">Czech Republic</option> <option data-id="35001095723" value="Denmark">Denmark</option> <option data-id="35001095724" value="Djibouti">Djibouti</option> <option data-id="35001095725" value="Dominica">Dominica</option> <option data-id="35001095726" value="Dominican Republic">Dominican Republic</option> <option data-id="35001095727" value="Ecuador">Ecuador</option> <option data-id="35001095728" value="Egypt">Egypt</option> <option data-id="35001095729" value="El Salvador">El Salvador</option> <option data-id="35001095730" value="Equatorial Guinea">Equatorial Guinea</option> <option data-id="35001095731" value="Eritrea">Eritrea</option> <option data-id="35001095732" value="Estonia">Estonia</option> <option data-id="35001095733" value="Eswatini">Eswatini</option> <option data-id="35001095734" value="Ethiopia">Ethiopia</option> <option data-id="35001095735" value="Fiji">Fiji</option> <option data-id="35001095736" value="Finland">Finland</option> <option data-id="35001095737" value="France">France</option> <option data-id="35001095738" value="Gabon">Gabon</option> <option data-id="35001095739" value="Gambia">Gambia</option> <option data-id="35001095740" value="Georgia">Georgia</option> <option data-id="35001095741" value="Germany">Germany</option> <option data-id="35001095742" value="Ghana">Ghana</option> <option data-id="35001095743" value="Greece">Greece</option> <option data-id="35001095744" value="Grenada">Grenada</option> <option data-id="35001095745" value="Guatemala">Guatemala</option> <option data-id="35001095746" value="Guinea">Guinea</option> <option data-id="35001095747" value="Guinea-Bissau">Guinea-Bissau</option> <option data-id="35001095748" value="Guyana">Guyana</option> <option data-id="35001095749" value="Haiti">Haiti</option> <option data-id="35001095750" value="Honduras">Honduras</option> <option data-id="35001095751" value="Hungary">Hungary</option> <option data-id="35001095752" value="Iceland">Iceland</option> <option data-id="35001095753" value="India">India</option> <option data-id="35001095754" value="Indonesia">Indonesia</option> <option data-id="35001095755" value="Iran">Iran</option> <option data-id="35001095756" value="Iraq">Iraq</option> <option data-id="35001095757" value="Ireland">Ireland</option> <option data-id="35001095758" value="Israel">Israel</option> <option data-id="35001095759" value="Italy">Italy</option> <option data-id="35001095760" value="Jamaica">Jamaica</option> <option data-id="35001095761" value="Japan">Japan</option> <option data-id="35001095762" value="Jordan">Jordan</option> <option data-id="35001095763" value="Kazakhstan">Kazakhstan</option> <option data-id="35001095764" value="Kenya">Kenya</option> <option data-id="35001095765" value="Kiribati">Kiribati</option> <option data-id="35001095766" value="Korea, North">Korea, North</option> <option data-id="35001095767" value="Korea, South">Korea, South</option> <option data-id="35001095768" value="Kosovo">Kosovo</option> <option data-id="35001095769" value="Kuwait">Kuwait</option> <option data-id="35001095770" value="Kyrgyzstan">Kyrgyzstan</option> <option data-id="35001095771" value="Laos">Laos</option> <option data-id="35001095772" value="Latvia">Latvia</option> <option data-id="35001095773" value="Lebanon">Lebanon</option> <option data-id="35001095774" value="Lesotho">Lesotho</option> <option data-id="35001095775" value="Liberia">Liberia</option> <option data-id="35001095776" value="Libya">Libya</option> <option data-id="35001095777" value="Liechtenstein">Liechtenstein</option> <option data-id="35001095778" value="Lithuania">Lithuania</option> <option data-id="35001095779" value="Luxembourg">Luxembourg</option> <option data-id="35001095780" value="Madagascar">Madagascar</option> <option data-id="35001095781" value="Malawi">Malawi</option> <option data-id="35001095782" value="Malaysia">Malaysia</option> <option data-id="35001095783" value="Maldives">Maldives</option> <option data-id="35001095784" value="Mali">Mali</option> <option data-id="35001095785" value="Malta">Malta</option> <option data-id="35001095786" value="Marshall Islands">Marshall Islands</option> <option data-id="35001095787" value="Mauritania">Mauritania</option> <option data-id="35001095788" value="Mauritius">Mauritius</option> <option data-id="35001095789" value="Mexico">Mexico</option> <option data-id="35001095790" value="Micronesia">Micronesia</option> <option data-id="35001095791" value="Moldova">Moldova</option> <option data-id="35001095792" value="Monaco">Monaco</option> <option data-id="35001095793" value="Mongolia">Mongolia</option> <option data-id="35001095794" value="Montenegro">Montenegro</option> <option data-id="35001095795" value="Morocco">Morocco</option> <option data-id="35001095796" value="Mozambique">Mozambique</option> <option data-id="35001095797" value="Myanmar">Myanmar</option> <option data-id="35001095798" value="Namibia">Namibia</option> <option data-id="35001095799" value="Nauru">Nauru</option> <option data-id="35001095800" value="Nepal">Nepal</option> <option data-id="35001095801" value="Netherlands">Netherlands</option> <option data-id="35001095802" value="New Zealand">New Zealand</option> <option data-id="35001095803" value="Nicaragua">Nicaragua</option> <option data-id="35001095804" value="Niger">Niger</option> <option data-id="35001095805" value="Nigeria">Nigeria</option> <option data-id="35001095806" value="North Macedonia">North Macedonia</option> <option data-id="35001095807" value="Norway">Norway</option> <option data-id="35001095808" value="Oman">Oman</option> <option data-id="35001095809" value="Pakistan">Pakistan</option> <option data-id="35001095810" value="Palau">Palau</option> <option data-id="35001095811" value="Palestine">Palestine</option> <option data-id="35001095812" value="Panama">Panama</option> <option data-id="35001095813" value="Papua New Guinea">Papua New Guinea</option> <option data-id="35001095814" value="Paraguay">Paraguay</option> <option data-id="35001095815" value="Peru">Peru</option> <option data-id="35001095816" value="Philippines">Philippines</option> <option data-id="35001095817" value="Poland">Poland</option> <option data-id="35001095818" value="Portugal">Portugal</option> <option data-id="35001095819" value="Qatar">Qatar</option> <option data-id="35001095820" value="Romania">Romania</option> <option data-id="35001095821" value="Russia">Russia</option> <option data-id="35001095822" value="Rwanda">Rwanda</option> <option data-id="35001095823" value="Saint Kitts and Nevis">Saint Kitts and Nevis</option> <option data-id="35001095824" value="Saint Lucia">Saint Lucia</option> <option data-id="35001095825" value="Saint Vincent and the Grenadines">Saint Vincent and the Grenadines</option> <option data-id="35001095826" value="Samoa">Samoa</option> <option data-id="35001095827" value="San Marino">San Marino</option> <option data-id="35001095828" value="Sao Tome and Principe">Sao Tome and Principe</option> <option data-id="35001095829" value="Saudi Arabia">Saudi Arabia</option> <option data-id="35001095830" value="Senegal">Senegal</option> <option data-id="35001095831" value="Serbia">Serbia</option> <option data-id="35001095832" value="Seychelles">Seychelles</option> <option data-id="35001095833" value="Sierra Leone">Sierra Leone</option> <option data-id="35001095834" value="Singapore">Singapore</option> <option data-id="35001095835" value="Slovakia">Slovakia</option> <option data-id="35001095836" value="Slovenia">Slovenia</option> <option data-id="35001095837" value="Solomon Islands">Solomon Islands</option> <option data-id="35001095838" value="Somalia">Somalia</option> <option data-id="35001095839" value="South Africa">South Africa</option> <option data-id="35001095840" value="South Sudan">South Sudan</option> <option data-id="35001095841" value="Spain">Spain</option> <option data-id="35001095842" value="Sri Lanka">Sri Lanka</option> <option data-id="35001095843" value="Sudan">Sudan</option> <option data-id="35001095844" value="Suriname">Suriname</option> <option data-id="35001095845" value="Sweden">Sweden</option> <option data-id="35001095846" value="Switzerland">Switzerland</option> <option data-id="35001095847" value="Syria">Syria</option> <option data-id="35001095848" value="Taiwan">Taiwan</option> <option data-id="35001095849" value="Tajikistan">Tajikistan</option> <option data-id="35001095850" value="Tanzania">Tanzania</option> <option data-id="35001095851" value="Thailand">Thailand</option> <option data-id="35001095852" value="Timor-Leste">Timor-Leste</option> <option data-id="35001095853" value="Togo">Togo</option> <option data-id="35001095854" value="Tonga">Tonga</option> <option data-id="35001095855" value="Trinidad and Tobago">Trinidad and Tobago</option> <option data-id="35001095856" value="Tunisia">Tunisia</option> <option data-id="35001095857" value="Turkey">Turkey</option> <option data-id="35001095858" value="Turkmenistan">Turkmenistan</option> <option data-id="35001095859" value="Tuvalu">Tuvalu</option> <option data-id="35001095860" value="Uganda">Uganda</option> <option data-id="35001095861" value="Ukraine">Ukraine</option> <option data-id="35001095862" value="United Arab Emirates">United Arab Emirates</option> <option data-id="35001095863" value="United Kingdom">United Kingdom</option> <option data-id="35001095864" value="United States">United States</option> <option data-id="35001095865" value="Uruguay">Uruguay</option> <option data-id="35001095866" value="Uzbekistan">Uzbekistan</option> <option data-id="35001095867" value="Vanuatu">Vanuatu</option> <option data-id="35001095868" value="Vatican City">Vatican City</option> <option data-id="35001095869" value="Venezuela">Venezuela</option> <option data-id="35001095870" value="Vietnam">Vietnam</option> <option data-id="35001095871" value="Yemen">Yemen</option> <option data-id="35001095872" value="Zambia">Zambia</option> <option data-id="35001095873" value="Zimbabwe">Zimbabwe</option></select> </div> </div> <div class="control-group ticket_section"> <label class=" control-label cf_address_for_hard_copy_767862-label " for="helpdesk_ticket_cf_address_for_hard_copy_767862">Delivery address for the hard copy (cost-free delivery)</label> <div class="controls "> <input class=" text section_field span12" placeholder="" type="text" name="helpdesk_ticket[custom_field][cf_address_for_hard_copy_767862]" id="helpdesk_ticket_custom_field_cf_address_for_hard_copy_767862" /> </div> </div>
Subject
Description
CAPTCHA verification is required.