{"id":541,"date":"2021-05-24T06:28:05","date_gmt":"2021-05-24T06:28:05","guid":{"rendered":"http:\/\/datainteractive.com.au\/forms\/?page_id=541"},"modified":"2022-03-08T20:38:37","modified_gmt":"2022-03-08T10:38:37","slug":"healthcare","status":"publish","type":"page","link":"https:\/\/datainteractive.com.au\/forms\/approvals\/healthcare\/","title":{"rendered":"Healthcare"},"content":{"rendered":"<p>[et_pb_section fb_built=&#8221;1&#8243; _builder_version=&#8221;4.9.4&#8243; _module_preset=&#8221;default&#8221; background_image=&#8221;http:\/\/datainteractive.com.au\/forms\/wp-content\/uploads\/2021\/05\/download-5.png&#8221; background_size=&#8221;initial&#8221; background_position=&#8221;center_right&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_row column_structure=&#8221;2_5,3_5&#8243; _builder_version=&#8221;4.9.0&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;2_5&#8243; _builder_version=&#8221;4.9.0&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_text _builder_version=&#8221;4.9.4&#8243; _module_preset=&#8221;default&#8221; text_font=&#8221;|600||on|||||&#8221; text_text_color=&#8221;gcid-215c4e82-7275-4c87-8ef8-aa9373653bec&#8221; text_font_size=&#8221;18px&#8221; custom_margin=&#8221;||10px|||&#8221; global_colors_info=&#8221;{%22gcid-215c4e82-7275-4c87-8ef8-aa9373653bec%22:%91%22text_text_color%22%93}&#8221;]<\/p>\n<p>HEALTHCARE APPROVAL FLOW<\/p>\n<p>[\/et_pb_text][et_pb_text _builder_version=&#8221;4.9.4&#8243; _module_preset=&#8221;default&#8221; text_font=&#8221;|300|||||||&#8221; header_2_font=&#8221;|700|||||||&#8221; header_2_text_align=&#8221;left&#8221; header_2_text_color=&#8221;gcid-066808c9-a723-4056-9269-50c10eb19d8a&#8221; header_2_font_size=&#8221;33px&#8221; header_2_line_height=&#8221;1.3em&#8221; custom_margin=&#8221;||12px|||&#8221; animation_style=&#8221;slide&#8221; animation_direction=&#8221;bottom&#8221; global_colors_info=&#8221;{%22gcid-066808c9-a723-4056-9269-50c10eb19d8a%22:%91%22header_2_text_color%22%93}&#8221;]<\/p>\n<h2>Automate your hospital management approval flow<\/h2>\n<p>[\/et_pb_text][et_pb_text _builder_version=&#8221;4.9.4&#8243; _module_preset=&#8221;default&#8221; text_font=&#8221;|300|||||||&#8221; animation_style=&#8221;slide&#8221; animation_direction=&#8221;bottom&#8221; global_colors_info=&#8221;{}&#8221;]Create automated approval flows for your healthcare organization with Data Interactive Approvals. Our healthcare workflow solution allows you to collect requests for medical supplies, appointment bookings, and more \u2014 and automatically assign submissions to members of your organization for approval.[\/et_pb_text][et_pb_button button_url=&#8221;https:\/\/datainteractive.com.au\/contact-us\/&#8221; button_text=&#8221;Get Started &#8211; Contact Us&#8221; button_alignment=&#8221;left&#8221; _builder_version=&#8221;4.14.8&#8243; _module_preset=&#8221;default&#8221; custom_button=&#8221;on&#8221; button_text_color=&#8221;#FFFFFF&#8221; button_bg_color=&#8221;#ff6600&#8243; button_border_width=&#8221;0px&#8221; button_border_radius=&#8221;0px&#8221; button_font=&#8221;|300|||||||&#8221; button_icon=&#8221;&#x24;||divi||400&#8243; button_on_hover=&#8221;off&#8221; button_text_size_tablet=&#8221;18px&#8221; button_text_size_phone=&#8221;16px&#8221; button_text_size_last_edited=&#8221;on|desktop&#8221; custom_css_main_element=&#8221;outline: 2px solid #ff6600;||    outline-offset: 1px;&#8221; global_colors_info=&#8221;{}&#8221; custom_css_main_element__hover_enabled=&#8221;on|hover&#8221; custom_css_main_element__hover=&#8221;outline: 2px solid #353535;||    outline-offset: 1px;&#8221; button_bg_color__hover_enabled=&#8221;on|hover&#8221; button_bg_color__hover=&#8221;#353535&#8243; button_bg_enable_color__hover=&#8221;on&#8221; theme_builder_area=&#8221;post_content&#8221;][\/et_pb_button][\/et_pb_column][et_pb_column type=&#8221;3_5&#8243; _builder_version=&#8221;4.9.0&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_image src=&#8221;http:\/\/datainteractive.com.au\/forms\/wp-content\/uploads\/2021\/05\/download-6.png&#8221; title_text=&#8221;download (6)&#8221; _builder_version=&#8221;4.9.4&#8243; _module_preset=&#8221;default&#8221; custom_margin=&#8221;|-35%|||false|false&#8221; custom_margin_tablet=&#8221;|0%|||false|false&#8221; custom_margin_phone=&#8221;&#8221; custom_margin_last_edited=&#8221;on|desktop&#8221; global_colors_info=&#8221;{}&#8221;][\/et_pb_image][\/et_pb_column][\/et_pb_row][\/et_pb_section][et_pb_section fb_built=&#8221;1&#8243; _builder_version=&#8221;4.9.4&#8243; _module_preset=&#8221;default&#8221; background_color=&#8221;gcid-066808c9-a723-4056-9269-50c10eb19d8a&#8221; background_image=&#8221;http:\/\/datainteractive.com.au\/forms\/wp-content\/uploads\/2021\/05\/download-1-2.png&#8221; background_size=&#8221;initial&#8221; background_position=&#8221;center_left&#8221; custom_padding=&#8221;||3%||false|false&#8221; custom_css_main_element=&#8221;background-size: auto 90% !important;||    background-position: top calc(50% &#8211; 5%) left calc(50% &#8211; 37.5rem) !important;&#8221; global_colors_info=&#8221;{%22gcid-066808c9-a723-4056-9269-50c10eb19d8a%22:%91%22background_color%22%93}&#8221;][et_pb_row column_structure=&#8221;2_5,3_5&#8243; _builder_version=&#8221;4.9.4&#8243; _module_preset=&#8221;default&#8221; custom_padding=&#8221;||5%||false|false&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;2_5&#8243; _builder_version=&#8221;4.9.4&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_divider show_divider=&#8221;off&#8221; _builder_version=&#8221;4.9.4&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][\/et_pb_divider][et_pb_text _builder_version=&#8221;4.9.4&#8243; _module_preset=&#8221;default&#8221; text_font=&#8221;|300|||||||&#8221; header_2_font=&#8221;|700|||||||&#8221; header_2_text_align=&#8221;left&#8221; header_2_text_color=&#8221;#FFFFFF&#8221; header_2_font_size=&#8221;33px&#8221; header_2_line_height=&#8221;1.3em&#8221; custom_margin=&#8221;||12px|||&#8221; animation_style=&#8221;slide&#8221; animation_direction=&#8221;bottom&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h2>Approve COVID-19 test requests<\/h2>\n<p>[\/et_pb_text][et_pb_text _builder_version=&#8221;4.9.4&#8243; _module_preset=&#8221;default&#8221; text_font=&#8221;|300|||||||&#8221; text_text_color=&#8221;#FFFFFF&#8221; animation_style=&#8221;slide&#8221; animation_direction=&#8221;bottom&#8221; global_colors_info=&#8221;{}&#8221;]Make sure patients get the medical tests they need. Collect and respond to requests for COVID-19 tests fast with our ready-to-use template.[\/et_pb_text][et_pb_button button_url=&#8221;https:\/\/datainteractive.com.au\/contact-us\/&#8221; url_new_window=&#8221;on&#8221; button_text=&#8221;Get Started &#8211; Contact Us&#8221; button_alignment=&#8221;left&#8221; _builder_version=&#8221;4.14.8&#8243; _module_preset=&#8221;default&#8221; custom_button=&#8221;on&#8221; button_text_color=&#8221;#FFFFFF&#8221; button_bg_color=&#8221;#ff6600&#8243; button_border_width=&#8221;0px&#8221; button_border_radius=&#8221;0px&#8221; button_font=&#8221;|300|||||||&#8221; button_icon=&#8221;&#x24;||divi||400&#8243; button_on_hover=&#8221;off&#8221; button_text_size_tablet=&#8221;18px&#8221; button_text_size_phone=&#8221;16px&#8221; button_text_size_last_edited=&#8221;on|desktop&#8221; custom_css_main_element=&#8221;outline: 2px solid #ff6600;||    outline-offset: 1px;&#8221; global_colors_info=&#8221;{}&#8221; custom_css_main_element__hover_enabled=&#8221;on|hover&#8221; custom_css_main_element__hover=&#8221;outline: 2px solid #ffffff;||    outline-offset: 1px;&#8221; button_bg_color__hover_enabled=&#8221;on|hover&#8221; button_bg_color__hover=&#8221;#ffffff&#8221; button_bg_enable_color__hover=&#8221;on&#8221; button_text_color__hover=&#8221;#353535&#8243; button_text_color__hover_enabled=&#8221;on|hover&#8221; theme_builder_area=&#8221;post_content&#8221;][\/et_pb_button][\/et_pb_column][et_pb_column type=&#8221;3_5&#8243; _builder_version=&#8221;4.9.4&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_tabs active_tab_background_color=&#8221;gcid-066808c9-a723-4056-9269-50c10eb19d8a&#8221; inactive_tab_background_color=&#8221;gcid-215c4e82-7275-4c87-8ef8-aa9373653bec&#8221; active_tab_text_color=&#8221;#FFFFFF&#8221; module_class=&#8221;custom-form-width&#8221; _builder_version=&#8221;4.9.4&#8243; _module_preset=&#8221;default&#8221; tab_text_color=&#8221;#FFFFFF&#8221; background_color=&#8221;#f6f8fb&#8221; border_radii=&#8221;on|10px|10px|10px|10px&#8221; border_width_all=&#8221;0px&#8221; global_colors_info=&#8221;{%22gcid-066808c9-a723-4056-9269-50c10eb19d8a%22:%91%22active_tab_background_color%22%93,%22gcid-215c4e82-7275-4c87-8ef8-aa9373653bec%22:%91%22inactive_tab_background_color%22%93}&#8221;][et_pb_tab title=&#8221;APPROVAL FLOW&#8221; _builder_version=&#8221;4.9.4&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<p><img loading=\"lazy\" src=\"http:\/\/datainteractive.com.au\/forms\/wp-content\/uploads\/2021\/05\/Capture.png\" width=\"595\" height=\"432\" alt=\"\" class=\"wp-image-557 alignnone size-full\" srcset=\"http:\/\/datainteractive.com.au\/forms\/wp-content\/uploads\/2021\/05\/Capture.png 595w, http:\/\/datainteractive.com.au\/forms\/wp-content\/uploads\/2021\/05\/Capture-480x349.png 480w\" sizes=\"(min-width: 0px) and (max-width: 480px) 480px, (min-width: 481px) 595px, 100vw\" \/><\/p>\n<p>[\/et_pb_tab][et_pb_tab title=&#8221;FORM&#8221; _builder_version=&#8221;4.9.4&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h1 class=\"first-form\"> COVID-19 Test Request Form <\/h1>\n<p><div role=\"form\" class=\"wpcf7\" id=\"wpcf7-f838-o1\" lang=\"en-US\" dir=\"ltr\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/forms\/wp-json\/wp\/v2\/pages\/541#wpcf7-f838-o1\" method=\"post\" class=\"wpcf7-form init\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"838\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"5.5.6\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f838-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_hidden_group_fields\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_hidden_groups\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_visible_groups\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_repeaters\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_steps\" value=\"{}\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_options\" value=\"{&quot;form_id&quot;:838,&quot;conditions&quot;:[],&quot;settings&quot;:{&quot;animation&quot;:&quot;yes&quot;,&quot;animation_intime&quot;:200,&quot;animation_outtime&quot;:200,&quot;conditions_ui&quot;:&quot;normal&quot;,&quot;notice_dismissed&quot;:false}}\" \/>\n<input type=\"hidden\" name=\"_wpcf7_recaptcha_response\" value=\"\" \/>\n<\/div>\n<div class=\"et_pb_row\">\n<div class=\"et_pb_column et_pb_column_4_4\">\n<h2 class=\"first-form\"> Patient Data <\/h2>\n<\/div>\n<\/div>\n<div class=\"et_pb_row\">\n<div class=\"et_pb_column et_pb_column_1_2\">\n<label>Name<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap first-name\"><input type=\"text\" name=\"first-name\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><br \/>\n<small> First Name <\/small>\n<\/div>\n<div class=\"et_pb_column et_pb_column_1_2\">\n<label><\/label><br \/>\n<span class=\"wpcf7-form-control-wrap last-name\"><input type=\"text\" name=\"last-name\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><br \/>\n<small> Last Name <\/small>\n<\/div>\n<\/div>\n<div class=\"et_pb_row\">\n<div class=\"et_pb_column et_pb_column_4_4\">\n<label>Age<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap your-age\"><input type=\"number\" name=\"your-age\" value=\"ex: 23\" class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span>\n<\/div>\n<\/div>\n<div class=\"et_pb_row\">\n<div class=\"et_pb_column et_pb_column_4_4\">\n<label>Gender<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap your-gender\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"your-gender\" value=\"Male\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Male<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"your-gender\" value=\"Female\" \/><span class=\"wpcf7-list-item-label\">Female<\/span><\/label><\/span><\/span><\/span>\n<\/div>\n<\/div>\n<div class=\"et_pb_row\">\n<div class=\"et_pb_column et_pb_column_4_4\">\n<label>Date of Birth<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap your-dob\"><input type=\"date\" name=\"your-dob\" value=\"\" class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><br \/>\n<small> Date <\/small>\n<\/div>\n<\/div>\n<div class=\"et_pb_row\">\n<div class=\"et_pb_column et_pb_column_4_4\">\n<label> Phone Number <\/label><br \/>\n<span class=\"wpcf7-form-control-wrap phone-number\"><input type=\"tel\" name=\"phone-number\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-tel wpcf7-validates-as-required wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><br \/>\n<small> Please enter a valid phone number. <\/small>\n<\/div>\n<\/div>\n<div class=\"et_pb_row\">\n<div class=\"et_pb_column et_pb_column_4_4\">\n<label> Email <\/label><br \/>\n<span class=\"wpcf7-form-control-wrap your-email\"><input type=\"email\" name=\"your-email\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-email wpcf7-validates-as-required wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><br \/>\n<small> example@example.com <\/small>\n<\/div>\n<\/div>\n<div class=\"et_pb_row\">\n<div class=\"et_pb_column et_pb_column_4_4\">\n<label> Address <\/label><br \/>\n<span class=\"wpcf7-form-control-wrap your-address1\"><input type=\"text\" name=\"your-address1\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><br \/>\n<small> Street Address <\/small>\n<\/div>\n<\/div>\n<div class=\"et_pb_row\">\n<div class=\"et_pb_column et_pb_column_4_4\">\n<span class=\"wpcf7-form-control-wrap your-address2\"><input type=\"text\" name=\"your-address2\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><br \/>\n<small> Street Address Line 2 <\/small>\n<\/div>\n<\/div>\n<div class=\"et_pb_row\">\n<div class=\"et_pb_column et_pb_column_1_2\">\n<span class=\"wpcf7-form-control-wrap your-city\"><input type=\"text\" name=\"your-city\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><br \/>\n<small> City <\/small>\n<\/div>\n<div class=\"et_pb_column et_pb_column_1_2\">\n<span class=\"wpcf7-form-control-wrap your-state\"><input type=\"text\" name=\"your-state\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><br \/>\n<small> Province \/ State <\/small>\n<\/div>\n<\/div>\n<div class=\"et_pb_row\">\n<div class=\"et_pb_column et_pb_column_4_4\">\n<span class=\"wpcf7-form-control-wrap postal-code\"><input type=\"text\" name=\"postal-code\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><br \/>\n<small>Postal\/Zip code<\/small>\n<\/div>\n<\/div>\n<div class=\"et_pb_row\">\n<div class=\"et_pb_column et_pb_column_4_4\">\n<label> Race\/Ethnicity <\/label><br \/>\n<span class=\"wpcf7-form-control-wrap your-ethnicity\"><input type=\"text\" name=\"your-ethnicity\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span>\n<\/div>\n<\/div>\n<div class=\"et_pb_row\">\n<div class=\"et_pb_column et_pb_column_4_4\">\n<label> Job Position\/Title <\/label><br \/>\n<span class=\"wpcf7-form-control-wrap your-position\"><input type=\"text\" name=\"your-position\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span>\n<\/div>\n<\/div>\n<div class=\"et_pb_row\">\n<div class=\"et_pb_column et_pb_column_4_4\">\n<label> Company Name <\/label><br \/>\n<span class=\"wpcf7-form-control-wrap company-name\"><input type=\"text\" name=\"company-name\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span>\n<\/div>\n<\/div>\n<div class=\"et_pb_row\">\n<div class=\"et_pb_column et_pb_column_4_4 custom_heading\">\n<h2 class=\"first-form\"> Health Related Data <\/h2>\n<\/div>\n<\/div>\n<div class=\"et_pb_row\">\n<div class=\"et_pb_column et_pb_column_4_4 custom_heading\">\n<label> Is the patient currently in a hospital or long-term care facility? <\/label><br \/>\n<span class=\"wpcf7-form-control-wrap patient-hospital\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"patient-hospital\" value=\"Yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"patient-hospital\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n<\/div>\n<\/div>\n<div class=\"et_pb_row\">\n<div class=\"et_pb_column et_pb_column_4_4 custom_heading\">\n<label> Is the patient undergoing dialysis? <\/label><br \/>\n<span class=\"wpcf7-form-control-wrap dialysis\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"dialysis\" value=\"Yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"dialysis\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n<\/div>\n<\/div>\n<div class=\"et_pb_row\">\n<div class=\"et_pb_column et_pb_column_4_4\">\n<label> Date when symptoms first appeared? <\/label><br \/>\n<span class=\"wpcf7-form-control-wrap symptoms-date\"><input type=\"date\" name=\"symptoms-date\" value=\"\" class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><br \/>\n<small> Date <\/small>\n<\/div>\n<\/div>\n<div class=\"et_pb_row\">\n<div class=\"et_pb_column et_pb_column_4_4\">\n<label> What are the symptoms you're currently experiencing? <\/label><br \/>\n<span class=\"wpcf7-form-control-wrap symptoms\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"symptoms[]\" value=\"Fever\" \/><span class=\"wpcf7-list-item-label\">Fever<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"symptoms[]\" value=\"Restlessness\" \/><span class=\"wpcf7-list-item-label\">Restlessness<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"symptoms[]\" value=\"Body ache\" \/><span class=\"wpcf7-list-item-label\">Body ache<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"symptoms[]\" value=\"Runny Nose\" \/><span class=\"wpcf7-list-item-label\">Runny Nose<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"symptoms[]\" value=\"Diarrhea\" \/><span class=\"wpcf7-list-item-label\">Diarrhea<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"symptoms[]\" value=\"Lethargic (Tiredness)\" \/><span class=\"wpcf7-list-item-label\">Lethargic (Tiredness)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"symptoms[]\" value=\"Dry Cough\" \/><span class=\"wpcf7-list-item-label\">Dry Cough<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"symptoms[]\" value=\"Nasal Congestion\" \/><span class=\"wpcf7-list-item-label\">Nasal Congestion<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"symptoms[]\" value=\"Loss of Smell\" \/><span class=\"wpcf7-list-item-label\">Loss of Smell<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"symptoms[]\" value=\"Loss of Apetite\" \/><span class=\"wpcf7-list-item-label\">Loss of Apetite<\/span><\/label><\/span><\/span><\/span>\n<\/div>\n<\/div>\n<div class=\"et_pb_row\">\n<div class=\"et_pb_column et_pb_column_4_4\">\n<label> Do you have any of the medical condition below: <\/label><br \/>\n<span class=\"wpcf7-form-control-wrap medical-condition\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"medical-condition[]\" value=\"Diabetes\" \/><span class=\"wpcf7-list-item-label\">Diabetes<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"medical-condition[]\" value=\"Cardiac Problems\" \/><span class=\"wpcf7-list-item-label\">Cardiac Problems<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"medical-condition[]\" value=\"Pregnant\" \/><span class=\"wpcf7-list-item-label\">Pregnant<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"medical-condition[]\" value=\"Liver Problems\" \/><span class=\"wpcf7-list-item-label\">Liver Problems<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"medical-condition[]\" value=\"Hypertension\" \/><span class=\"wpcf7-list-item-label\">Hypertension<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"medical-condition[]\" value=\"Immunocompromised\" \/><span class=\"wpcf7-list-item-label\">Immunocompromised<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"medical-condition[]\" value=\"Chronic Respiratory Disease\" \/><span class=\"wpcf7-list-item-label\">Chronic Respiratory Disease<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"medical-condition[]\" value=\"Kidney Problems\" \/><span class=\"wpcf7-list-item-label\">Kidney Problems<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"medical-condition[]\" value=\"Other\" \/><span class=\"wpcf7-list-item-label\">Other<\/span><\/label><\/span><\/span><\/span>\n<\/div>\n<\/div>\n<div class=\"et_pb_row\">\n<div class=\"et_pb_column et_pb_column_4_4\">\n<label> Collection Date <\/label><br \/>\n<span class=\"wpcf7-form-control-wrap collection-date\"><input type=\"date\" name=\"collection-date\" value=\"\" class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><br \/>\n<small> Date <\/small>\n<\/div>\n<\/div>\n<div class=\"et_pb_row\">\n<div class=\"et_pb_column et_pb_column_4_4\">\n<label> Specimen Type <\/label><br \/>\n<span class=\"wpcf7-form-control-wrap specimen-type\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"specimen-type\" value=\"Acute\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Acute<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"specimen-type\" value=\"Convalescent\" \/><span class=\"wpcf7-list-item-label\">Convalescent<\/span><\/label><\/span><\/span><\/span>\n<\/div>\n<\/div>\n<div class=\"et_pb_row\">\n<div class=\"et_pb_column et_pb_column_4_4\">\n<label> Specimen Source <\/label><br \/>\n<span class=\"wpcf7-form-control-wrap specimen-source\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"specimen-source\" value=\"Nasal\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Nasal<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"specimen-source\" value=\"Oropharyngeal\" \/><span class=\"wpcf7-list-item-label\">Oropharyngeal<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"specimen-source\" value=\"Nasopharyngeal\" \/><span class=\"wpcf7-list-item-label\">Nasopharyngeal<\/span><\/label><\/span><\/span><\/span>\n<\/div>\n<\/div>\n<div class=\"et_pb_row\">\n<div class=\"et_pb_column et_pb_column_4_4\">\n<label> Have you been tested for influenza? <\/label><br \/>\n<span class=\"wpcf7-form-control-wrap tested-influenza\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"tested-influenza\" value=\"Yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"tested-influenza\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n<\/div>\n<\/div>\n<div class=\"et_pb_row\">\n<div class=\"et_pb_column et_pb_column_4_4\">\n<label> Have you been tested for COVID-19 <\/label><br \/>\n<span class=\"wpcf7-form-control-wrap testedfor-COVID-19\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"testedfor-COVID-19\" value=\"Yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"testedfor-COVID-19\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n<\/div>\n<\/div>\n<div class=\"et_pb_row\">\n<div class=\"et_pb_column et_pb_column_4_4\">\n<h2 class=\"first-form\"> Acknowledgment and Consent <\/h2>\n<\/div>\n<\/div>\n<div class=\"et_pb_row\">\n<div class=et_pb_column et_pb_column_4_4\">\n<label><\/p>\n<ul>\n<li>I acknowledge that all information I entered in this form is accurate and true.<\/li>\n<li>I authorize this facility to collect a sample specimen for me in order to perform this test.\n<\/li>\n<li>I release the facility and all of its employees and affiliates, from any liabilities, damage, or accidents related to this testing activity.\n<\/li>\n<li>I authorize this facility to share with the requester (e.g company) my health care information including diagnostic test results and medical test results.\n<\/li>\n<li>I understand that this diagnostic test is for informational purposes only. This facility will not admit patients or provide medical advice.\n<\/li>\n<\/ul>\n<p><\/label><br \/>\n<span class=\"wpcf7-form-control-wrap acceptance-714\"><span class=\"wpcf7-form-control wpcf7-acceptance\"><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"acceptance-714\" value=\"1\" aria-invalid=\"false\" \/><span class=\"wpcf7-list-item-label\">I acknowledge and give my consent for this COVID-19 test request.<\/span><\/label><\/span><\/span><\/span>\n<\/div>\n<\/div>\n<div class=\"et_pb_row\">\n<div class=\"et_pb_column et_pb_column_4_4\">\n<label> Patient Signature <\/label><br \/>\n<div class=\"wpcf7-form-control-signature-global-wrap\" data-field-id=\"signature\">\n\t\t\t\t<div class=\"wpcf7-form-control-signature-wrap\" style=\"width:150px;height:100px;\">\n\t\t\t\t\t<div class=\"wpcf7-form-control-signature-body\">\n\t\t\t\t\t\t<canvas data-color=\"#000000\" data-background=\"#ffffff\" id=\"wpcf7_signature_signature\" class=\"signature\"><\/canvas>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"wpcf7-form-control-clear-wrap\">\n\t\t\t\t\t<input id=\"wpcf7_signature_clear\" type=\"button\" value=\"Clear\"\/>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t<span class=\"wpcf7-form-control-wrap wpcf7-form-control-signature-input-wrap signature\">\n\t\t\t\t<input type=\"hidden\" name=\"signature\" value=\"\" aria-invalid=\"false\" id=\"wpcf7_input_signature\"\/><input type=\"hidden\" name=\"signature-attachment\" value=\"\" id=\"wpcf7_input_signature_attachment\"\/><input type=\"hidden\" name=\"signature-inline\" value=\"\" id=\"wpcf7_input_signature_inline\"\/>\n\t\t\t<\/span>\n\t\t\t\n<\/div>\n<\/div>\n<div class=\"et_pb_row\">\n<div class=\"et_pb_column et_pb_column_4_4\">\n<input type=\"submit\" value=\"Submit\" class=\"wpcf7-form-control has-spinner wpcf7-submit\" \/>\n<\/div>\n<\/div>\n<div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div><\/form><\/div>[\/et_pb_tab][\/et_pb_tabs][\/et_pb_column][\/et_pb_row][\/et_pb_section][et_pb_section fb_built=&#8221;1&#8243; module_class=&#8221;reverse_on_mbl&#8221; _builder_version=&#8221;4.9.4&#8243; _module_preset=&#8221;default&#8221; background_image=&#8221;http:\/\/datainteractive.com.au\/forms\/wp-content\/uploads\/2021\/05\/download-2-1.png&#8221; background_size=&#8221;initial&#8221; background_position=&#8221;center_right&#8221; custom_css_main_element=&#8221;background-size: auto 90% !important;||    background-position: top calc(50% &#8211; 5%) right calc(50% &#8211; 31.25rem) !important;&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_row column_structure=&#8221;3_5,2_5&#8243; _builder_version=&#8221;4.9.4&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;3_5&#8243; _builder_version=&#8221;4.9.4&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_divider show_divider=&#8221;off&#8221; _builder_version=&#8221;4.9.4&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][\/et_pb_divider][et_pb_tabs active_tab_background_color=&#8221;gcid-066808c9-a723-4056-9269-50c10eb19d8a&#8221; inactive_tab_background_color=&#8221;gcid-215c4e82-7275-4c87-8ef8-aa9373653bec&#8221; active_tab_text_color=&#8221;#FFFFFF&#8221; module_class=&#8221;custom-form-width&#8221; _builder_version=&#8221;4.9.4&#8243; _module_preset=&#8221;default&#8221; tab_text_color=&#8221;#FFFFFF&#8221; background_color=&#8221;#f6f8fb&#8221; border_radii=&#8221;on|10px|10px|10px|10px&#8221; border_width_all=&#8221;0px&#8221; global_colors_info=&#8221;{%22gcid-066808c9-a723-4056-9269-50c10eb19d8a%22:%91%22active_tab_background_color%22%93,%22gcid-215c4e82-7275-4c87-8ef8-aa9373653bec%22:%91%22inactive_tab_background_color%22%93}&#8221;][et_pb_tab title=&#8221;APPROVAL FLOW&#8221; _builder_version=&#8221;4.9.4&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<p><img loading=\"lazy\" src=\"http:\/\/datainteractive.com.au\/forms\/wp-content\/uploads\/2021\/05\/Capture1.png\" width=\"618\" height=\"454\" alt=\"\" class=\"wp-image-572 alignnone size-full\" srcset=\"http:\/\/datainteractive.com.au\/forms\/wp-content\/uploads\/2021\/05\/Capture1.png 618w, http:\/\/datainteractive.com.au\/forms\/wp-content\/uploads\/2021\/05\/Capture1-480x353.png 480w\" sizes=\"(min-width: 0px) and (max-width: 480px) 480px, (min-width: 481px) 618px, 100vw\" \/><\/p>\n<p>[\/et_pb_tab][et_pb_tab title=&#8221;FORM&#8221; _builder_version=&#8221;4.9.4&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;]<div role=\"form\" class=\"wpcf7\" id=\"wpcf7-f851-o2\" lang=\"en-US\" dir=\"ltr\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/forms\/wp-json\/wp\/v2\/pages\/541#wpcf7-f851-o2\" method=\"post\" class=\"wpcf7-form init\" enctype=\"multipart\/form-data\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"851\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"5.5.6\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f851-o2\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_hidden_group_fields\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_hidden_groups\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_visible_groups\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_repeaters\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_steps\" value=\"{}\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_options\" value=\"{&quot;form_id&quot;:851,&quot;conditions&quot;:[{&quot;then_field&quot;:&quot;previous-dose-yes&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;previous-dose&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;medical-insurance-yes&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;medical-insurance&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]}],&quot;settings&quot;:{&quot;animation&quot;:&quot;yes&quot;,&quot;animation_intime&quot;:200,&quot;animation_outtime&quot;:200,&quot;conditions_ui&quot;:&quot;normal&quot;,&quot;notice_dismissed&quot;:false}}\" \/>\n<input type=\"hidden\" name=\"_wpcf7_recaptcha_response\" value=\"\" \/>\n<\/div>\n<div class=\"et_pb_row\">\n<div class=\"et_pb_column et_pb_column_4_4\">\n<img src=\"http:\/\/datainteractive.com.au\/forms\/wp-content\/uploads\/2021\/05\/Hendricks_Name_1200C.6003f5217ca799.41096529.jpg\">\n<\/div>\n<\/div>\n<div class=\"et_pb_row\">\n<div class=\"et_pb_column et_pb_column_4_4\">\n<h3 class=\"second-form\">COVID-19 Vaccine Appointment and Consent Form<\/h3>\n<p class=\"second-form\">In order to receive the vaccine, you must be in the most appropriate phase of the vaccine rollout. Visit this link (https:\/\/www.cdc.gov\/coronavirus\/2019-ncov\/vaccines\/recommendations.html) for more information at the federal level. States and\/or local authorities may have a different approach. Be prepared to show identification to justify your qualification to receive the vaccine.<\/p>\n<\/div>\n<\/div>\n<div class=\"et_pb_row\">\n<label>Vaccine Recipient Name*<\/label><\/p>\n<div class=\"et_pb_column et_pb_column_1_3\">\n<span class=\"wpcf7-form-control-wrap first-name\"><input type=\"text\" name=\"first-name\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><br \/>\n<small>First Name<\/small>\n<\/div>\n<div class=\"et_pb_column et_pb_column_1_3\">\n<span class=\"wpcf7-form-control-wrap middle-name\"><input type=\"text\" name=\"middle-name\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><br \/>\n<small>Middle Name<\/small>\n<\/div>\n<div class=\"et_pb_column et_pb_column_1_3\">\n<span class=\"wpcf7-form-control-wrap last-name\"><input type=\"text\" name=\"last-name\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><br \/>\n<small>Last Name<\/small>\n<\/div>\n<\/div>\n<div class=\"et_pb_row\">\n<label>Vaccine Recipient Physical Address*<\/label><\/p>\n<div class=\"et_pb_column et_pb_column_4_4\">\n<span class=\"wpcf7-form-control-wrap your-address\"><input type=\"text\" name=\"your-address\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><br \/>\n<small>Street Address<\/small>\n<\/div>\n<\/div>\n<div class=\"et_pb_row\">\n<div class=\"et_pb_column et_pb_column_1_2\">\n<span class=\"wpcf7-form-control-wrap your-city\"><input type=\"text\" name=\"your-city\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><br \/>\n<small>City<\/small>\n<\/div>\n<div class=\"et_pb_column et_pb_column_1_2\">\n<span class=\"wpcf7-form-control-wrap your-state\"><input type=\"text\" name=\"your-state\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><br \/>\n<small>State Initials<\/small>\n<\/div>\n<\/div>\n<div class=\"et_pb_row\">\n<div class=\"et_pb_column et_pb_column_4_4\">\n<span class=\"wpcf7-form-control-wrap your-postal\"><input type=\"text\" name=\"your-postal\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><br \/>\n<small>Postal \/ Zip Code<\/small>\n<\/div>\n<\/div>\n<div class=\"et_pb_row\">\n<label>Email (to receive notification of appointment and informational documents)<\/label><\/p>\n<div class=\"et_pb_column et_pb_column_4_4\">\n<span class=\"wpcf7-form-control-wrap your-email\"><input type=\"email\" name=\"your-email\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-email wpcf7-validates-as-required wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><br \/>\n<small>example@example.com<\/small>\n<\/div>\n<\/div>\n<div class=\"et_pb_row\">\n<div class=\"et_pb_column et_pb_column_1_2\">\n<label>Date of Birth<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap date-birth\"><input type=\"date\" name=\"date-birth\" value=\"\" class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span>\n<\/div>\n<div class=\"et_pb_column et_pb_column_1_2\">\n<label>Gender at birth<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap gender\"><select name=\"gender\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"\">---<\/option><option value=\"Please Select\">Please Select<\/option><option value=\"Male\">Male<\/option><option value=\"Female\">Female<\/option><\/select><\/span>\n<\/div>\n<\/div>\n<div class=\"et_pb_row\">\n<div class=\"et_pb_column et_pb_column_1_2\">\n<label>Race<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap race\"><select name=\"race\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"\">---<\/option><option value=\"Please Select\">Please Select<\/option><option value=\"American Indian or Alaska Native\">American Indian or Alaska Native<\/option><option value=\"Asian\">Asian<\/option><option value=\"Native Hawaiian or Other Pecific Islander\">Native Hawaiian or Other Pecific Islander<\/option><option value=\"Black or African American\">Black or African American<\/option><option value=\"White\">White<\/option><option value=\"Other Race\">Other Race<\/option><\/select><\/span>\n<\/div>\n<div class=\"et_pb_column et_pb_column_1_2\">\n<label>Ethnicity<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap ethnic\"><select name=\"ethnic\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"\">---<\/option><option value=\"Please Select\">Please Select<\/option><option value=\"Hispanic or Latino\">Hispanic or Latino<\/option><option value=\"Non Hispanic or Latino\">Non Hispanic or Latino<\/option><option value=\"Unknown\">Unknown<\/option><\/select><\/span>\n<\/div>\n<\/div>\n<div class=\"et_pb_row\">\n<div class=\"et_pb_column et_pb_column_4_4\">\n<label>Vaccine Recipient Phone Number<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap your-phone\"><input type=\"tel\" name=\"your-phone\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-tel wpcf7-validates-as-required wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span>\n<\/div>\n<\/div>\n<div class=\"et_pb_row\">\n<div class=\"et_pb_column et_pb_column_4_4\">\n<label>Mother's Maiden Name<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap mother-name\"><input type=\"tel\" name=\"mother-name\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-tel wpcf7-validates-as-required wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><br \/>\n<small>Required for proper vaccine documentation<\/small>\n<\/div>\n<\/div>\n<div class=\"et_pb_row\">\n<div class=\"et_pb_column et_pb_column_4_4\">\n<label>Primary Care Provider Name<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap provider-name\"><input type=\"text\" name=\"provider-name\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><br \/>\n<small>If you would like to have a copy of this record sent to your Primary Care Provider, please provide name here.<\/small>\n<\/div>\n<\/div>\n<div class=\"et_pb_row\">\n<div class=\"et_pb_column et_pb_column_1_2\">\n<label>Emergency Contact Name<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap contact-name\"><input type=\"text\" name=\"contact-name\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span>\n<\/div>\n<div class=\"et_pb_column et_pb_column_1_2\">\n<label>Relationship to Emergency Contact<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap relationship-name\"><input type=\"text\" name=\"relationship-name\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span>\n<\/div>\n<\/div>\n<div class=\"et_pb_row\">\n<div class=\"et_pb_column et_pb_column_4_4\">\n<label>Phone Number of Emergency Contact<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap emergency-contact\"><input type=\"tel\" name=\"emergency-contact\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-tel wpcf7-validates-as-required wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span>\n<\/div>\n<\/div>\n<div class=\"et_pb_row\">\n<div class=\"et_pb_column et_pb_column_4_4\">\n<label>COVID-19 Previous Dose<\/label><\/p>\n<p><label>Have you ever received a dose of COVID-19 Vaccine?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap previous-dose\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><span class=\"wpcf7-list-item-label\">Yes<\/span><input type=\"checkbox\" name=\"previous-dose\" value=\"Yes\" \/><\/label><\/span><span class=\"wpcf7-list-item last\"><label><span class=\"wpcf7-list-item-label\">No<\/span><input type=\"checkbox\" name=\"previous-dose\" value=\"No\" \/><\/label><\/span><\/span><\/span><\/p>\n<div data-id=\"previous-dose-yes\" data-orig_data_id=\"previous-dose-yes\"  class=\"\" data-class=\"wpcf7cf_group\">\n<div class=\"et_pb_row\">\n<div class=\"et_pb_column et_pb_column_4_4\">\n<label>COVID-19 Vaccine Manufacturer for the first dose received <\/label><br \/>\n<span class=\"wpcf7-form-control-wrap first-dose-receive\"><select name=\"first-dose-receive\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Please Select\">Please Select<\/option><option value=\"MOderna\">MOderna<\/option><option value=\"Pfizer\">Pfizer<\/option><option value=\"Other\">Other<\/option><\/select><\/span>\n<\/div>\n<\/div>\n<div class=\"et_pb_row\">\n<div class=\"et_pb_column et_pb_column_4_4\">\n<label>Date of first dose of COVID-19 Vaccine <\/label><br \/>\n<span class=\"wpcf7-form-control-wrap first-dose-date\"><input type=\"date\" name=\"first-dose-date\" value=\"\" class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span>\n<\/div>\n<\/div>\n<div class=\"et_pb_row\">\n<div class=\"et_pb_column et_pb_column_4_4\">\n<label>Previous COVID-19 vaccine dose <\/label><br \/>\n<label>Have you ever had an allergic reaction to a previous dose of COVID-19 Vaccine?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap allergic-reaction\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><span class=\"wpcf7-list-item-label\">Yes<\/span><input type=\"checkbox\" name=\"allergic-reaction\" value=\"Yes\" \/><\/span><span class=\"wpcf7-list-item last\"><span class=\"wpcf7-list-item-label\">No<\/span><input type=\"checkbox\" name=\"allergic-reaction\" value=\"No\" \/><\/span><\/span><\/span>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<div class=\"et_pb_row\">\n<div class=\"et_pb_column et_pb_column_4_4\">\n<p>COVID-19 Vaccine Screening Questions (If you answer \u201cyes\u201d to any question, it does not necessarily mean you should not be vaccinated. It just means additional information may be necessary before vaccination.)<\/p>\n<\/div>\n<\/div>\n<div class=\"et_pb_row\">\n<div class=\"et_pb_column et_pb_column_4_4 col-border\">\n<label>1. Have you ever had an allergic reaction to acomponent of the COVID-19 vaccine, including polyethylene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap question1\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><span class=\"wpcf7-list-item-label\">Yes<\/span><input type=\"checkbox\" name=\"question1\" value=\"Yes\" \/><\/label><\/span><span class=\"wpcf7-list-item last\"><label><span class=\"wpcf7-list-item-label\">No<\/span><input type=\"checkbox\" name=\"question1\" value=\"No\" \/><\/label><\/span><\/span><\/span>\n<\/div>\n<div class=\"et_pb_column et_pb_column_4_4 col-border\">\n<label>2. Have you ever had an allergic reaction toPolysorbate?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap question2\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><span class=\"wpcf7-list-item-label\">Yes<\/span><input type=\"checkbox\" name=\"question2\" value=\"Yes\" \/><\/label><\/span><span class=\"wpcf7-list-item last\"><label><span class=\"wpcf7-list-item-label\">No<\/span><input type=\"checkbox\" name=\"question2\" value=\"No\" \/><\/label><\/span><\/span><\/span>\n<\/div>\n<div class=\"et_pb_column et_pb_column_4_4 col-border\">\n<label>3. Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap question3\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><span class=\"wpcf7-list-item-label\">Yes<\/span><input type=\"checkbox\" name=\"question3\" value=\"Yes\" \/><\/label><\/span><span class=\"wpcf7-list-item last\"><label><span class=\"wpcf7-list-item-label\">No<\/span><input type=\"checkbox\" name=\"question3\" value=\"No\" \/><\/label><\/span><\/span><\/span>\n<\/div>\n<div class=\"et_pb_column et_pb_column_4_4 col-border\">\n<label>4. Have you ever had a severe allergic reaction (e.g., anaphylaxis) to something other than a component of COVID-19 vaccine, polysorbate, or any vaccine or injectable medication? This would include food, pet, environmental, or oral medication allergies.\t<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap question4\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><span class=\"wpcf7-list-item-label\">Yes<\/span><input type=\"checkbox\" name=\"question4\" value=\"Yes\" \/><\/label><\/span><span class=\"wpcf7-list-item last\"><label><span class=\"wpcf7-list-item-label\">No<\/span><input type=\"checkbox\" name=\"question4\" value=\"No\" \/><\/label><\/span><\/span><\/span>\n<\/div>\n<div class=\"et_pb_column et_pb_column_4_4 col-border\">\n<label>5. Have you received any vaccine in the last 14 days?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap question5\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><span class=\"wpcf7-list-item-label\">Yes<\/span><input type=\"checkbox\" name=\"question5\" value=\"Yes\" \/><\/label><\/span><span class=\"wpcf7-list-item last\"><label><span class=\"wpcf7-list-item-label\">No<\/span><input type=\"checkbox\" name=\"question5\" value=\"No\" \/><\/label><\/span><\/span><\/span>\n<\/div>\n<div class=\"et_pb_column et_pb_column_4_4 col-border\">\n<label>6. Have you ever had a positive test for COVID-19 or has a health care provider ever told you that you had COVID-19?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap question6\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><span class=\"wpcf7-list-item-label\">Yes<\/span><input type=\"checkbox\" name=\"question6\" value=\"Yes\" \/><\/label><\/span><span class=\"wpcf7-list-item last\"><label><span class=\"wpcf7-list-item-label\">No<\/span><input type=\"checkbox\" name=\"question6\" value=\"No\" \/><\/label><\/span><\/span><\/span>\n<\/div>\n<div class=\"et_pb_column et_pb_column_4_4 col-border\">\n<label>7. Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19? [note: monoclonal antibodies does not include antibiotics that you would be prescribed and filled at a pharmacy]\t<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap question7\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><span class=\"wpcf7-list-item-label\">Yes<\/span><input type=\"checkbox\" name=\"question7\" value=\"Yes\" \/><\/label><\/span><span class=\"wpcf7-list-item last\"><label><span class=\"wpcf7-list-item-label\">No<\/span><input type=\"checkbox\" name=\"question7\" value=\"No\" \/><\/label><\/span><\/span><\/span>\n<\/div>\n<div class=\"et_pb_column et_pb_column_4_4 col-border\">\n<label>8. Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap question8\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><span class=\"wpcf7-list-item-label\">Yes<\/span><input type=\"checkbox\" name=\"question8\" value=\"Yes\" \/><\/label><\/span><span class=\"wpcf7-list-item last\"><label><span class=\"wpcf7-list-item-label\">No<\/span><input type=\"checkbox\" name=\"question8\" value=\"No\" \/><\/label><\/span><\/span><\/span>\n<\/div>\n<div class=\"et_pb_column et_pb_column_4_4 col-border\">\n<label>9. Do you have a bleeding disorder or are you taking a blood thinner?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap question9\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><span class=\"wpcf7-list-item-label\">Yes<\/span><input type=\"checkbox\" name=\"question9\" value=\"Yes\" \/><\/label><\/span><span class=\"wpcf7-list-item last\"><label><span class=\"wpcf7-list-item-label\">No<\/span><input type=\"checkbox\" name=\"question9\" value=\"No\" \/><\/label><\/span><\/span><\/span>\n<\/div>\n<div class=\"et_pb_column et_pb_column_4_4 col-border\">\n<label>10. Are you pregnant or breastfeeding?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap question10\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><span class=\"wpcf7-list-item-label\">Yes<\/span><input type=\"checkbox\" name=\"question10\" value=\"Yes\" \/><\/label><\/span><span class=\"wpcf7-list-item last\"><label><span class=\"wpcf7-list-item-label\">No<\/span><input type=\"checkbox\" name=\"question10\" value=\"No\" \/><\/label><\/span><\/span><\/span>\n<\/div>\n<\/div>\n<div class=\"et_pb_row\">\n<div class=\"et_pb_column et_pb_column_4_4\">\n<p>Consent (check each box below after reading and prior to signing the form)<\/p>\n<\/div>\n<\/div>\n<div class=\"et_pb_row\">\n<div class=\"et_pb_column et_pb_column_4_4 col-border\">\n<label>I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) Fact Sheet (the Moderna Fact Sheet is available after clicking submit), a copy of which I was provided with this Consent Form. I have had a chance to ask questions that were answered to my satisfaction. I request the vaccine to be given to me or to the person named above, a minor for whom I represent that I am authorized to sign this Consent Form.<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap condition1\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><span class=\"wpcf7-list-item-label\">Check the Box<\/span><input type=\"checkbox\" name=\"condition1[]\" value=\"Check the Box\" \/><\/label><\/span><\/span><\/span>\n<\/div>\n<div class=\"et_pb_column et_pb_column_4_4 col-border\">\n<label>I understand that at this time, the COVID-19 vaccine requires 2 doses given 21-28 days apart depending on the manufacturer. If this is my second dose, I will bring my vaccine card with me to be completed.<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap condition2\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><span class=\"wpcf7-list-item-label\">Check the Box<\/span><input type=\"checkbox\" name=\"condition2[]\" value=\"Check the Box\" \/><\/label><\/span><\/span><\/span>\n<\/div>\n<div class=\"et_pb_column et_pb_column_4_4 col-border\">\n<label>I agree to stay in the vaccine administration area for fifteen (15) minutes or longer if indicated by the vaccine administrator after receiving my vaccine to ensure that no immediate adverse reactions occur.<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap condition3\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><span class=\"wpcf7-list-item-label\">Check the Box<\/span><input type=\"checkbox\" name=\"condition3[]\" value=\"Check the Box\" \/><\/label><\/span><\/span><\/span>\n<\/div>\n<div class=\"et_pb_column et_pb_column_4_4 col-border\">\n<label>I acknowledge that my immunization information from this visit will be sent to the California Immunization Registry unless I choose to opt out.<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap condition4\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><span class=\"wpcf7-list-item-label\">Check the Box<\/span><input type=\"checkbox\" name=\"condition4[]\" value=\"Check the Box\" \/><\/label><\/span><\/span><\/span>\n<\/div>\n<div class=\"et_pb_column et_pb_column_4_4 col-border\">\n<label>I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless Hendricks Pharmacy, its subsidiaries, divisions, affiliates, agents, officers, directors, contractors, and employees from any and all claims arising out of, in connection with, or in any way related to the administration of the vaccine(s).<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap condition5\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><span class=\"wpcf7-list-item-label\">Check the Box<\/span><input type=\"checkbox\" name=\"condition5[]\" value=\"Check the Box\" \/><\/label><\/span><\/span><\/span>\n<\/div>\n<div class=\"et_pb_column et_pb_column_4_4 col-border\">\n<label>I have read and reviewed the Notice of Privacy Practices available at www.HendricksPharmacy.flashrx.com.<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap condition6\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><span class=\"wpcf7-list-item-label\">Check the Box<\/span><input type=\"checkbox\" name=\"condition6[]\" value=\"Check the Box\" \/><\/label><\/span><\/span><\/span>\n<\/div>\n<div class=\"et_pb_column et_pb_column_4_4 col-border\">\n<label>I understand that I will be receiving the vaccination at no cost to me.<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap condition7\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><span class=\"wpcf7-list-item-label\">Check the Box<\/span><input type=\"checkbox\" name=\"condition7[]\" value=\"Check the Box\" \/><\/label><\/span><\/span><\/span>\n<\/div>\n<\/div>\n<div class=\"et_pb_row\">\n<div class=\"et_pb_column et_pb_column_4_4\">\n<label>Insurance (The vaccine is available to anyone no matter if insured or uninsured.)<\/label>\n<\/div>\n<div class=\"et_pb_column et_pb_column_4_4 col-border\">\n<label>Do you have health or medical insurance (examples include Medicare, Medi-Cal, or private health policies)?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap medical-insurance\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><span class=\"wpcf7-list-item-label\">Yes<\/span><input type=\"checkbox\" name=\"medical-insurance\" value=\"Yes\" \/><\/label><\/span><span class=\"wpcf7-list-item last\"><label><span class=\"wpcf7-list-item-label\">No<\/span><input type=\"checkbox\" name=\"medical-insurance\" value=\"No\" \/><\/label><\/span><\/span><\/span><\/p>\n<div data-id=\"medical-insurance-yes\" data-orig_data_id=\"medical-insurance-yes\"  class=\"\" data-class=\"wpcf7cf_group\">\n<div class=\"et_pb_row\">\n<div class=\"et_pb_column et_pb_column_4_4\">\n<p>The vaccine is available to anyone no matter if insured or uninsured. Since you indicated you have insurance, please read and check this box.<\/p>\n<\/div>\n<\/div>\n<div class=\"et_pb_row\">\n<div class=\"et_pb_column et_pb_column_4_4\">\n<label>If INSURED, check this box attesting to bringing in your prescription and medical insurance cards for your vaccine appointment. By selecting this, you are also authorizing the pharmacy to bill your insurance on your behalf for the immunization \u2013 understanding you will not incur any costs.<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap vaccine-condition\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><span class=\"wpcf7-list-item-label\">Check the Box<\/span><input type=\"checkbox\" name=\"vaccine-condition[]\" value=\"Check the Box\" \/><\/label><\/span><\/span><\/span>\n<\/div>\n<\/div>\n<div class=\"et_pb_row\">\n<div class=\"et_pb_column et_pb_column_4_4\">\n<label>Insurance Card (front & back)<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap insurance-card\"><input type=\"file\" name=\"insurance-card\" size=\"40\" class=\"wpcf7-form-control wpcf7-file\" accept=\".png,.jpeg,.jpg,.gif,.pdf,.txt\" aria-invalid=\"false\" \/><\/span>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<div class=\"et_pb_row\">\n<div class=\"et_pb_column et_pb_column_4_4\">\n<label>Select an appointment time<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap appointment-date\"><input type=\"text\" name=\"appointment-date\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required walcf7-datetimepicker\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span>\n<\/div>\n<\/div>\n<div class=\"et_pb_row\">\n<div class=\"et_pb_column et_pb_column_4_4\">\n<input type=\"submit\" value=\"Submit Consent Form (required)\" class=\"wpcf7-form-control has-spinner wpcf7-submit\" \/>\n<\/div>\n<\/div>\n<div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div><\/form><\/div>[\/et_pb_tab][\/et_pb_tabs][\/et_pb_column][et_pb_column type=&#8221;2_5&#8243; _builder_version=&#8221;4.9.4&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_text _builder_version=&#8221;4.9.4&#8243; _module_preset=&#8221;default&#8221; text_font=&#8221;|300|||||||&#8221; header_2_font=&#8221;|700|||||||&#8221; header_2_text_align=&#8221;left&#8221; header_2_text_color=&#8221;gcid-066808c9-a723-4056-9269-50c10eb19d8a&#8221; header_2_font_size=&#8221;33px&#8221; header_2_line_height=&#8221;1.3em&#8221; custom_margin=&#8221;||12px|||&#8221; animation_style=&#8221;slide&#8221; animation_direction=&#8221;bottom&#8221; global_colors_info=&#8221;{%22gcid-066808c9-a723-4056-9269-50c10eb19d8a%22:%91%22header_2_text_color%22%93}&#8221;]<\/p>\n<h2>Streamline Appointment Scheduling<\/h2>\n<p>[\/et_pb_text][et_pb_text _builder_version=&#8221;4.9.4&#8243; _module_preset=&#8221;default&#8221; text_font=&#8221;|300|||||||&#8221; animation_style=&#8221;slide&#8221; animation_direction=&#8221;bottom&#8221; global_colors_info=&#8221;{}&#8221;]Simplify appointments with an automated approval flow template you can customize for your needs to get patients their vaccinations faster.[\/et_pb_text][et_pb_button button_url=&#8221;https:\/\/datainteractive.com.au\/contact-us\/&#8221; button_text=&#8221;Get Started &#8211; Contact Us&#8221; button_alignment=&#8221;left&#8221; _builder_version=&#8221;4.14.8&#8243; _module_preset=&#8221;default&#8221; custom_button=&#8221;on&#8221; button_text_color=&#8221;#FFFFFF&#8221; button_bg_color=&#8221;#ff6600&#8243; button_border_width=&#8221;0px&#8221; button_border_radius=&#8221;0px&#8221; button_font=&#8221;|300|||||||&#8221; button_icon=&#8221;&#x24;||divi||400&#8243; button_on_hover=&#8221;off&#8221; button_text_size_tablet=&#8221;18px&#8221; button_text_size_phone=&#8221;16px&#8221; button_text_size_last_edited=&#8221;on|desktop&#8221; custom_css_main_element=&#8221;outline: 2px solid #ff6600;||    outline-offset: 1px;&#8221; global_colors_info=&#8221;{}&#8221; custom_css_main_element__hover_enabled=&#8221;on|hover&#8221; custom_css_main_element__hover=&#8221;outline: 2px solid #353535;||    outline-offset: 1px;&#8221; button_bg_color__hover_enabled=&#8221;on|hover&#8221; button_bg_color__hover=&#8221;#353535&#8243; button_bg_enable_color__hover=&#8221;on&#8221; 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_builder_version=&#8221;4.9.4&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;]<div role=\"form\" class=\"wpcf7\" id=\"wpcf7-f853-o3\" lang=\"en-US\" dir=\"ltr\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/forms\/wp-json\/wp\/v2\/pages\/541#wpcf7-f853-o3\" method=\"post\" class=\"wpcf7-form init\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"853\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"5.5.6\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f853-o3\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_hidden_group_fields\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_hidden_groups\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_visible_groups\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_repeaters\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_steps\" value=\"{}\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_options\" value=\"{&quot;form_id&quot;:853,&quot;conditions&quot;:[],&quot;settings&quot;:{&quot;animation&quot;:&quot;yes&quot;,&quot;animation_intime&quot;:200,&quot;animation_outtime&quot;:200,&quot;conditions_ui&quot;:&quot;normal&quot;,&quot;notice_dismissed&quot;:false}}\" \/>\n<input type=\"hidden\" name=\"_wpcf7_recaptcha_response\" value=\"\" \/>\n<\/div>\n<div class=\"et_pb_row\">\n<div class=\"et_pb_column et_pb_column_4_4\">\n<h2 class=\"dovid-19\"> COVID-19 Treatment Consent Form <\/h2>\n<\/div>\n<\/div>\n<div class=\"et_pb_row\">\n<div class=\"et_pb_column et_pb_column_1_2\">\n<label> Name * <\/label><br \/>\n<span class=\"wpcf7-form-control-wrap first-name\"><input type=\"text\" name=\"first-name\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><br \/>\n<small> First Name <\/small>\n<\/div>\n<div class=\"et_pb_column et_pb_column_1_2\">\n<label>  <\/label><br \/>\n<span class=\"wpcf7-form-control-wrap last-name\"><input type=\"text\" name=\"last-name\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><br \/>\n<small> Last Name <\/small>\n<\/div>\n<\/div>\n<div class=\"et_pb_row\">\n<div class=\"et_pb_column et_pb_column_1_2\">\n<label> Email * <\/label><br \/>\n<span class=\"wpcf7-form-control-wrap your-email\"><input type=\"email\" name=\"your-email\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-email wpcf7-validates-as-required wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><br \/>\n<small> example@example.com <\/small>\n<\/div>\n<div class=\"et_pb_column et_pb_column_1_2\">\n<label>Date * <\/label><br \/>\n<span class=\"wpcf7-form-control-wrap date\"><input type=\"date\" name=\"date\" value=\"\" class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" min=\"1980-01-01\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><br \/>\n<small> Date <\/small>\n<\/div>\n<\/div>\n<p><label> I understand the novel coronavirus causes the disease known as COVID-19. I understand the novel coronavirus has a long incubation period during which carriers of the virus may not show symptoms but still be contagious.* <\/label><\/p>\n<div class=\"et_pb_row\">\n<div class=\"et_pb_column et_pb_column_1_3\">\n<span class=\"wpcf7-form-control-wrap dropdown-1\"><select name=\"dropdown-1\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Please Select\">Please Select<\/option><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span>\n<\/div>\n<\/div>\n<p><label><br \/>\nI confirm that I am NOT presenting with any of the following symptoms of COVID-19: A fever (Higher than 38 degrees Celsius), a new cough or a regression of a chronic cough, a sore throat that is not related to a known or pre-existing condition, a runny nose that is not related to a known or pre-existing condition shortness of breath that is not related to known or pre-existing condition, a recent loss of taste or smell current flu-like symptoms such as nausea, vomiting, or diarrhea.* <\/label><\/p>\n<div class=\"et_pb_row\">\n<div class=\"et_pb_column et_pb_column_1_3\">\n<span class=\"wpcf7-form-control-wrap dropdown-2\"><select name=\"dropdown-2\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Please Select\">Please Select<\/option><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span>\n<\/div>\n<\/div>\n<p><label><br \/>\nI confirm that if I am in a high risk category including: diabetes, cardiovascular disease, hypertension, lung diseases including moderate to severe asthma, being immunocompromised, having active malignancy, or over the age of 65, I have discussed the risks with my therapist and I agree to proceed with treatment.*<br \/>\n<\/label><\/p>\n<div class=\"et_pb_row\">\n<div class=\"et_pb_column et_pb_column_1_3\">\n<span class=\"wpcf7-form-control-wrap dropdown-3\"><select name=\"dropdown-3\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Please Select\">Please Select<\/option><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span>\n<\/div>\n<\/div>\n<p><label><br \/>\nI confirm that I am NOT currently positive for the novel coronavirus.*<\/p>\n<p><\/label><\/p>\n<div class=\"et_pb_row\">\n<div class=\"et_pb_column et_pb_column_1_3\">\n<span class=\"wpcf7-form-control-wrap dropdown-3\"><select name=\"dropdown-3\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Please Select\">Please Select<\/option><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span>\n<\/div>\n<\/div>\n<p><label><br \/>\nI confirm that I am NOT currently waiting for the results of a laboratory test for the novel coronavirus.*<br \/>\n<\/label><\/p>\n<div class=\"et_pb_row\">\n<div class=\"et_pb_column et_pb_column_1_3\">\n<span class=\"wpcf7-form-control-wrap dropdown-4\"><select name=\"dropdown-4\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Please Select\">Please Select<\/option><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span>\n<\/div>\n<\/div>\n<p><label><br \/>\nI confirm that I have NOT returned from any country outside of my hometown in the past 14 days.*<\/p>\n<p><\/label><\/p>\n<div class=\"et_pb_row\">\n<div class=\"et_pb_column et_pb_column_1_3\">\n<span class=\"wpcf7-form-control-wrap dropdown-5\"><select name=\"dropdown-5\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Please Select\">Please Select<\/option><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span>\n<\/div>\n<\/div>\n<p><label><br \/>\nI confirm that I have NOT been in close contact with someone who has tested positive for the novel coronavirus or someone who has been required to self-isolate within the last 10 days.*<\/p>\n<p><\/label><\/p>\n<div class=\"et_pb_row\">\n<div class=\"et_pb_column et_pb_column_1_3\">\n<span class=\"wpcf7-form-control-wrap dropdown-6\"><select name=\"dropdown-6\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Please Select\">Please Select<\/option><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span>\n<\/div>\n<\/div>\n<p><label><br \/>\nI verify the information I have provided on this consent form is truthful and accurate. I knowingly and willingly consent to having treatment.*<\/p>\n<p><\/label><\/p>\n<div class=\"et_pb_row\">\n<div class=\"et_pb_column et_pb_column_1_3\">\n<span class=\"wpcf7-form-control-wrap dropdown-7\"><select name=\"dropdown-7\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Please Select\">Please Select<\/option><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span>\n<\/div>\n<\/div>\n<div class=\"et_pb_row\">\n<div class=\"et_pb_column et_pb_column_1_2\">\n<\/div>\n<div class=\"et_pb_column et_pb_column_1_2\">\n<input type=\"submit\" value=\"Submit\" class=\"wpcf7-form-control has-spinner wpcf7-submit\" \/>\n<\/div>\n<div class=\"et_pb_column et_pb_column_1_2\">\n<\/div>\n<\/div>\n<div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div><\/form><\/div>[\/et_pb_tab][\/et_pb_tabs][\/et_pb_column][\/et_pb_row][\/et_pb_section]<\/p>\n","protected":false},"excerpt":{"rendered":"<p>HEALTHCARE APPROVAL FLOWAutomate your hospital management approval flowCreate automated approval flows for your healthcare organization with Data Interactive Approvals. Our healthcare workflow solution allows you to collect requests for medical supplies, appointment bookings, and more \u2014 and automatically assign submissions to members of your organization for approval.Approve COVID-19 test requestsMake sure patients get the medical [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":450,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_et_pb_use_builder":"on","_et_pb_old_content":"","_et_gb_content_width":""},"_links":{"self":[{"href":"https:\/\/datainteractive.com.au\/forms\/wp-json\/wp\/v2\/pages\/541"}],"collection":[{"href":"https:\/\/datainteractive.com.au\/forms\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/datainteractive.com.au\/forms\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/datainteractive.com.au\/forms\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/datainteractive.com.au\/forms\/wp-json\/wp\/v2\/comments?post=541"}],"version-history":[{"count":37,"href":"https:\/\/datainteractive.com.au\/forms\/wp-json\/wp\/v2\/pages\/541\/revisions"}],"predecessor-version":[{"id":1502,"href":"https:\/\/datainteractive.com.au\/forms\/wp-json\/wp\/v2\/pages\/541\/revisions\/1502"}],"up":[{"embeddable":true,"href":"https:\/\/datainteractive.com.au\/forms\/wp-json\/wp\/v2\/pages\/450"}],"wp:attachment":[{"href":"https:\/\/datainteractive.com.au\/forms\/wp-json\/wp\/v2\/media?parent=541"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}