cannot read answer please decipher

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    jrpemman5
    Asked on June 07, 2021 at 06:54 PM

    https://www.jotform.com/inbox/210968452568063/4988477080539754617

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    Have you had an allergic reaction after being vaccinated before?

    KyLj0uWQDFGEhqLdHSI97fWpRDLTxa/Rw+Uj5szAG5DbKtYpEE3+BXkzixqZFD9zoU/iZCMXwxelboOvJvaEzW/wx0VT16bL8QldKvY4MWwOPQq3FHfRBgyiik2BXC9wvx4dGp5DPq1Cfhh7sf5eUTb8d6tTY3SOca60CpjEZKGOCRh/PBkDxtSt8y1fJBWgbebjocmigu5DwcTsFQfKmAfPHJK1KbC+qflvLGUWA5HDU341Xfg1MWSuLnmhtVZCltVDskc5nXxLen+WJIIZSm2Dc8kX49J6OhY+cLiF0sPuwguQKvFcje7saxhJizgygWXmW5VIGZYKs5jtA6vJKQ==


    Do you have a mast cell disorder?

    DtGvQHeeFiqKpWT944tLm4BnYLyvPWkUh+uESW9SSA1azevzVzJsP8fzoH5+hJdFmNqXvz4Gyz7cTgYzAXB7Xfn6CR6ujg6dme3Qho+HFL7DMxWh736oFH1IUGDaoCeZbrFiyJ7KgKtkWLjgOmlnRpDV5W687FiGV8Y+aiPcenSjK2eYPMgaIk4loZrBPpooFfouL00+TrgKK5G2OuTSbxHJXxMADGUpHAspYRl6U1J4Z8VCltyy+a8U67bZ/Ca0ORMcE4sTkWWyujxNaehqxIApaT8ovUQFETyN8Qgx5xrdJki9+Hf6mv75Voam7wyRaEw54XiANNaE6wERXcp4Ow==


    Have you had COVID-19 before?

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    Do you have a bleeding disorder?

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    Do you take any medicine to thin your blood (an anticoagulant therapy)?

    CzfMOm5Ai6FGlNQ2P38LnAScfMmNVr7+SZEzpbmKpxDOt57h1iZKlXuMpEGqnU77e+5zCWcLry+D/RUGYTsqFx+/fk3Sh8j3uOBQcsZDd1+G6ucLr/FCwm5wlR9xluF+nVDkzBSZ+h74rbdsfD0kr4Iu0cZoI5julik1O9jDjP47tg5APKfI0epfb1F5ndrVZu2WP19lFmkwH2GbUxNrH+xtBk6/MJtHneF39raRwOsnxnkqNHXFlS3a/oFOB3KKkwL69pWgjIMY/hFqjb2rdBmlTODougU/mxKbC34EDXMbSx6ZL8+dW+/NY8ye+8Sm9cgFy9Gc5MLKxJ3vnMgMeg==


    Do you have a weakened immune system (immunocompromised)?

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    Are you pregnant (having a baby) or think you might be pregnant?

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    Are you planning to get pregnant?

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    Are you breastfeeding?

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    Have you been sick with a cough, sore throat, fever or are feeling sick in another way?

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    Have you had a COVID-19 vaccination before?

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    Have received any other vaccination in the last 14 days?

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    Have you had cerebral venous sinus thrombosis in the past?

    XRjAhT4iOIm1wsaPVrgvMSFhAt8jkDHdH5wvz4tjD6GU8wGDuwmczHSRHlAfec6t9gg5ZXylrqBZo0rgcWUO4ulf8fBWYmzbYXLC+HcgVvfjL9R+64QLUlmoW+wo96YHYSG3k2q0ctnSPR5FEOGu4d+396cWxGVetJ1fwQLLXIUqUrlIhhgkaUJDhnIVanHxZzG4oQM4tgSHUNxwMFTF+vYs7AAtgh6pQY7pR0gh8vfVIZIRdSlg+u211bMP2rxg/FDnGyZUEzAxDaSPh4Y23+rqVk3sV7uZNMqWD5RcaqIL3/tsxIlBxDF+4meEhT9JbBY6zMStZBl7aBghl+f/7g==


    Have you had heparin-induced thrombocytopenia in the past?

    RcfIS8/uuU6eERPKawLIXx+5b0SElMqHaModWjE94m2tD//DFACHA4+WLm7ktbYHEWrHEYg1/5qnwFR9UNYT8Ih0ZEw2XpBg0wqw33ymG5ZxMJYS/Rr/JGnDSwTdwVioXIupI4kYRRR1FJu2l+LNNSeTcothEJFSNqVGMH4Vy0R4tdySvR9j+iHEfwrdfnycpNEg0Rvcuim76onewL0boNJy4wxFnr6uWFhwNXpXolPFtK3C/6wM4xA9chyWnq6PaWmYW/uqFA8nee5+utwjGSeji71jFdJpKxskhp+n3XXP8ppYbINqCt41SfeweoBo2Y/bZQ2weMHPrqpPiK0bLw==


    Are you under 50 years of age?

    NPAKJkPCkZ5N2YsZv4EzvS37ltfolE0bjLz7Eg4yZC25YClwgEqGant5qEi6T7DP8VzWbHQtLa2h29OWkcrHUpJWJW0JL/kN832uH8xTrf9zCVRCKswpcpNvsc+UCKwCdBlhsEsK+1SjVOIirA5GELzVX0HL4cC9BOJCy9bJzT7I0K4fEa71hdI7MIvGvVyIWrOOUTQ8Hd/0hVU04icG2ICJoGmnQeFbgeLE4bXFzilkEO6YzzgghFwwQtZkxmQXgALarbsgb3FjeQsnW9W/vQX74VOhBug9oMBeBo7VUUMGw6DG+rD0DGg60GFxwxDNd3TnoFb6qTRFb8dDQI60lA==


    Name

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    Medicare Card:

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    Date of Birth:

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    Address:

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    Phone Contact Number :

    VsCVBWOTghyempdzE/+s2IBxemF1CLl/tUmKQ9LGtTYBU5MqhoMh1tm3Rm7T4+tZzyvNUGtA+Vkfd+Apstm84h4BoV6IAVX1Zc8B9uCtBBdfcVki6SV5/TJNY+D9yppByIMBZNQ4Mn5jVLOc/yb79fwtvnuyW1/QNFQQJXJHipcePpXgEgj3Uj5QS1KZV1N9YWPlCGauE8t9DOtiAbPgJUuyItqnoUhN0gWvVjbeCns83l4sJqFUT5A7MszBW2y76LUG92uMrpuSK2GmD6Wj7UfWzbJ4spha2z9AJ1/LE9WUSwsAdTihdHK5MGYaqxIA+Vett58zD8YzhIH9oUE17A==


    Email

    Um/BXAJEAppv0tWODJgqmyz4Rk4FuwQlZhuOvydr1Ykk+60GomMAivNtDXwpgR0S+EMb0IZwcFH3oQB2AGCXLzHv155MQSOePQuBwRGDTnwRL7b6GltyVJKEk1Dz/LufF6d9B6eWvditUpeypBN4LspZVTO3K/KEYwdDSufTY+5gLzuMDyn+J83M85tWWT4UKQulVKQ1VAqk3+NXGZHuESZnWeUra2PMj7YjZzSKy5U59jzeTWZLnJWMy/lXvVkUhR+lbwNAfUX/Mdh3Pzt9JliC9jp3VOonET0DGIY2YQ0lDCphm9R440tMp+v8FzRZkQNJSum21kkOXk8VPiQPjg==


    Sex :

    ELZLAXrpDluWTH+zXlIOcVD2nW2lrI8XsNvgyHbRyOjmaMe1fcrbdfRAoYYymcJixRUmCYkNwGwq+OAtHTeyEifbll5bzag5TZoVmHAn/F0GdpPcR+GzP/3V24dTD0v3x0ywiUCgdS5S9WhCsB4ZIDdxTD2ReTKdqDZgiIMHc9uz50qfptaWkcVUeL+UGEAQ+LXlGDpdnn7r8EPwh9JHra6TIMa/LSBGEQdJXmaJVxKNrprVnXVtjsqs/gDwD1N8L3k9iCj8yYOz1eu54p3gx4x0DeaHXc5QPTONBy6BxO/n2nwPYwlOblK8zEMlNj24zf829beRZ4vPoIWC3aSb7A==


    Are you Aboriginal and/or Torres Strait Islander?

    Oa5wpi/U/oGBWszGmRCHNGRv0qJUEEv2dj/gH244+/z2YAGSU65lq7LrPUBHH53RQ7/v98a2HQ7ta9Vj4QE/wvpm2s/meQ4cUM5PHVocGvu+YbECJ+vG1xkwx3kCE77Xs/4yrB1o+ty/7xUIvU2UTaRcCdkETunJSCWym/jY928c63QjRORsfrP6LcskcXbqpuzZSAGx3kWvc6XJ/qpKA5XCv345kat8UXYXnEr9TG1N0FIP/bTwe0Qi3ywWiOQ8sUYRpFdzoAzTdHVI94ICl6mg31oYysJKsgcIQVC/TaGx2Fp05ojHSu9PF66JsnT5QOV63fiFtIE4dPiyhnu7Cg==


    Next of kin (in case of emergency) Name and Contact Number:

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    I confirm that I have received and understood information provided to me on COVID-19 vaccination

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    I confirm that none of the conditions above apply, or I have discussed these and/or any other special circumstances with my regular health care provider and/or vaccination service provider

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    I agree to receive a course of COVID-19 vaccine (two doses of the same vaccine)

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    Name

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  • Profile Image
    Rehan
    Answered on June 08, 2021 at 12:54 AM

    Greetings,

    This is a duplicate ticket. We will respond to your ticket on the link below.

    https://www.jotform.com/answers/3145762

    Thanks