-
jrpemman5Asked on June 7, 2021 at 6:54 PM
https://www.jotform.com/inbox/210968452568063/4988477080539754617
NLB4teRMw8yfR10Gjkh7vCX3fKO5BWHb2bTRqmZAP2NrhLTdnI7o3r4utcQlkqWJ3jRHBrK9OEIEj8b6Xcxy2R4+JKAr+nBhdHbZc5Jb9IuK/cVS+bckCT014lS1vOE0muoh5Rt1dRjtFtuC1UAk3f9EzJUUcJW8JnojwXDMY3LMkdFIUi+WxHFzRH045CDtaZ4ONqmSKA0grSkwemv7QsghxQA4XUNx0Y9zokOws6fSZfEhJ95D3ZVBDa7n531mTDBdXo2r49q1v7a9cMJQivXqW6FNhdzWEnppe489r4IcK/qhUHWaCJK3eKs/H+B4kBp4UOxu4+mx3i/KuYS0eQ==
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?
EDSc4buSBlrEHHOkMPJNY81RRFiRsKC6tlMrbIsiZ7Dq7QjGgtO9Whk9cPB2/HxWSp2JEzvrC/1Wa8McysMIBYqVccnGJreE8nzh/aEBdMbNy6BEn+JKzoIJabIX5XX15Wc/3vweFm+kqkMP76Hle3Ao9ebZQY7qeb73gecQHLw8VQHOUswqYy5cZvLe/BtnEAhDrqwrXFK6bgmBm/c1G7Sl2WKLZeUOwkDqFtnQCWQlAVxxGtl80yvJ5uLsmxnQu9oVb+xSNJbMB4mjfwHx3lXBIcfjyS/fFyYgpp6svOoGn1BwvutserFs9oLtN5oetVs0wF5/qBu0kShFDZB0oA==
Do you have a bleeding disorder?
RKnOxokaZ9qb9zcSvaf2RGWgIdXo83CXuPv1OVcFkw308SntWJqHtMAuZAFl34jFOo2Hehs4bPbmsFcGR0XRx51BnMT92hxGVHnP5VB5+/mhuuDRGUEveY2Ov+ucIUQip62dXM6XqQPnGMsOE3xXfyEpb3pBm7wl5YRGPKk5jSrLmyz56eWKPhyU7SJprS2AqM+CRk7r0Gc0UdZ7gqCBRmU7yhHVepCrJHMfzH6fzNGYTGbZm0MpJUSJfQBl49/722h6nHoEDkt1xJO0kyirO0kCmuUTwiW/wSV+aMP8os5/m+OJNqJeycNp/w4VDw1H6+pA9Hqund12ti+G9n4EDA==
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)?
KeiSrWWIoRUCNIiDIIWROEFoefSCDjD1u44xfW6SN5Ya5MDxg37OcS7ZLDl68yhVni2v8oQbANtzs7mYUZF4i1ea91XrG1KafdZaLmMfYWyg8JlkK5NvhEPsROXcwUywtc/b05Lhqc9RIdBKJq5Jv5+dByI9bKHMLpleIlHTYF6eO4lvGvp6RS/k9Nv6Os/X6xObFCJWN9iAykYnr7nyUZBrXCQC3Npudsb0HIyyV92waW5eYVmCw6+/3JXXV4hHyXJPVUEPOxFcWjf+DvX2dq4D5AOcfQMl3B6lknKa9EJlJWo1U3LVEB0ozXwbx5ItyRtK26vi5qbde8J/HICr4w==
Are you pregnant (having a baby) or think you might be pregnant?
NyKqIV1kUaMJ/LGbnket3ePNPtONwGz4+nF9fDUmaSQA5722kpSPVyGRiZFUlNaYt5KJOpn5Zqxgi9jzDQ8QA47rCaDiv2qYZuWxoBiWZIcBBCNtYpb1KDxceoY9F5tpqe0Dw8bkixQd5Q0qO94A4cI7ciMm70/AVu9NAFdyxpjoVRU8q1gJ9R9hbsc3WPFHN1aC4hHHteVyXh5/vvOv/y9s7yTsXKjoSyMJ2myz0nf0+seSUChHa5P2Y1cfgdAvRAZunWKgfEMn2XV6+UJ+XDoDF/gxCraYLgvNeCgjjjPO0MRtYW9vfSdrFx0RPB/IAEzjun24zUDLyf46RkBjFA==
Are you planning to get pregnant?
TaRy7vvO1I85Y86cctD4YLdiNWwAL7xGo5GYeEvwsqQVNkABW7ICpXIqnZT/CyqHKTtz3DvPqHXPiKaV9A0b3ebffu50510ThUgjvRNFCyLgt2Sv0xMH0Og72YXEVFxZgcHi5HNF59QeYIAakd9EimGDlriKzKmv5yJVTIJIqfS0SaHUt0fbSViBd+TNM7XlsgM4CAp2ZYkrE8mw1Wi9TQ61lTxHwccnBfzfpFlZOFHI0izZTBa73hhl+HEtdGI6ZrK/s2kWo5Ljcb8ltPcFQErZPRQtrxVneXHqyFvX5Zxa42OAJuWNXwqy1aXgjXAlA3zBiOMW8gQn5Ca2MrLg2Q==
Are you breastfeeding?
EgWUwrqKvRKJVdumjFllXFkDMiXqKDbE0cWP93WlDhGiDfiRsXIicpNevDmorIHnkCoy6mVaDCSWo+wFMQMhQZceXQxLR7rqyCyVTxdzJKeGFQdATQbf4NsFgPuSi9H8QsHG5Yp6hAysNPYVqg9Y0EoyS9R+xjGcCgBlwpRsF7zeOOs0DVg4W31qDK/rsU2ZOaVmiAnjxTJ+3XjkD/605begHO5QgxRju5Ed+/W+Jz241kybru0qgTk9nGVUpEti3gWcFA0lt3c2thNGNkXSIsu+QhkgI4CVQtN6VrwR90xoXKntGr1rgq2QaQNgQoq9XmRWZNDV0e3t0P9++7E8ZA==
Have you been sick with a cough, sore throat, fever or are feeling sick in another way?
HMuB7m94ire4dufTToC07ScQ/WAO8KOvQANrYJBObwV3Ilecfb8yfSbYOi99BqlHk4cHayHImU12gDtyydWdfgWP4RQWzSPn236Ea04VR6rzXOmNeYOM248rzVZPP/UHB9a2OCoZfY8DplnRnB+tkC/U3oQUqCcLIUnFsn64HohwlAiuHu7oaC5A4WLXW61Z481zKNNIBBbgw4mqwbkyH+JJjEftyUMICUaRRtX1C/j2vYU9K619PVYMSnPM0bGIueBQOSzQyVCR0NavLs88oAPrcvUxfRO9DS/qW5YV+j7fqafNuLgGN6dMARSpd7Fzh24GwtnqGRRDIB/SFzmSiA==
Have you had a COVID-19 vaccination before?
Jho2iKdFQIckYxlF9PENFsHXKy3zk9bSU190QayRl4wJ7FmAjueqgleE4lzhqkZbIbt9PQgEWKA5xazpq4kORPNZDJrnMBIDT972LDnfaYQX7Nf8AA9+TGbXzUxFah26GBzAs3nWjAPMg5Vbzaivn869HmQsp8R8hsIhTnECE3zRLXlC2Ho+zpp1SUaXUJ9nuWydPPk6FdJ0iuz3FC2DCUQF+5rbAjf1NNxDjSPukEIZMfoT/MEi4w5rR8dkXDotxPJ0jte0MZYAn0SzRykoJoR4kRsbW1PFOt4EvXUV666KNMRxuDta/LpMktu1uHbOGyHcwYmuetrtog/c4CBKQw==
Have received any other vaccination in the last 14 days?
NC2RkdzTWB0pB78Hy8ir/sYtG6WQ5ZIW9IDHilXGFIVHyJpqn1rQThHQaf/bqK3LuAfNEajzMMwMvZFWsc2jMxGUnA5EK36dm1oQAbymU4WLXJWNsqRe5UsPiH1Nklt7UE6UylFsaytvenec2vlLEHj+AhbJOfCaz4UnvDMSddCRHtEFcq3BGqL86b8GWBSs0zdaebC1X9dYbWowl58ZZIrTXKJTwYprDDfmzWPd9BBwG9uExQXVXhcDjsQQ7ZoVt+yzgXSX/djYZCwk6AUj5ZEoyvrV3uGMjnpjlkKbMe41gbAyDKg3Mzo+IbxKYQc+Ze35+xOromJuwZQVBYrhGA==
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
YPGA18SsDs0T57Sa9LkHyIaymOLM8tyXMbI1FQOsbCfRYn7tTOnTXprp2r4ViYMddgvqkMiVtmc0w9RWdCXaJyYu1Cr7o6m9L2Zs3ISG3EHRNajtL39C+MQm9TbZp3/6fVkZs1wEwM6fsoVvzdSOdKZz3qTMi9qfTsUHGpAQ6QofXIBO+tay7xvKapW+oT6/1rkGaVuiLJ9SuRhhdm7NyBx7hDn9WG5TRYGc1OQaLvDODR1VEg+rsHNZSal/K4q19OG+8wT/DhyjNZxAQoZ1syVV9Z+xsEGOxMjZSc9b1tAgGit9H8AEX+gFDmpFCkvbh2whFNYCWfFBIOFey445Cw== U+p31IbQ6JXDo/EfqaoaY3tRb5DLSqptI2JvB6rshZtNQcLXgYI1NHAYh+5J2Wd8YMEcN+H04yJgNXtdXsd41I4LugsL3Oz9HaBZ9ek3QCyiVdF6JPFjUgQS3OMO06NcPVKwf/lS9xwfzb4jcnXxAiCPSE0tFjvm5hla83VIb1LDf2I2sZeUtOco5eYS8EaArRD6EKZQgmXh3HG6WtenzwT0pyffp1fNr77jvLtL9pSGFVl/PpqS0vPOdX23VP5CZKau9b757X+V9k/zchNEH2KFCV8g6tMt45heb8ORq0JCR7gjneF45XA7paj7dPIjUcv2dkLAZ7bG0oBIGKuWYA==
Medicare Card:
CYz1Ps8KrGVxRjtxnnxi6VPZ2p9l+1yKZB+PSbmDB5LmBdP8PzMK6tYq3eUKxLpvxv6Y9DZygub7+1bfwRIeVD63kB1reLaNwmtgJVvI1cUNWvkxQMAVMARhk9An58CQP4jxEea39r3pEb/5ZFOvQGipbEc8Xu4/GJhfu483TUwMh1/jn7FQrcARDlGdVooWbvubi50E3eUW/23g4c2svySmIgwHmBOO5B74nDeQJvf03WzCfNGpn41QAi/9wXg+19et6djrq6m0SDdc7UMMhJ9wUqakCh4v5GqRnBUQBgEajU3d+w/5Use+pmVCldnPHozqBidJwq4Wqsjnf6Up6Q==
Date of Birth:
W5F/oG52hUrpHKZaU3nV1IZ6uMQUeqyRS+SUKnbx/FFpyALLU7qkRr2sVau0nuAXPU4fOpN2V0MXnm0WyeEU40lF5PoONATJygaUDiCyU/wPHAocbAHa33khUvTdn9JbGBhn5sO0zIKTpdrDcutU7+8xrqnpcBM8lCdRNS63bE8im3lLC4jMpCit9VbMvBWvQPOsy41/WLWvBKCc4ZZ570GDFxtvkvy/FDQYrE5c9BwxMANh1KPBINaF+cSw1nQBHFfqNb0kF/R7UJrG46SrL0kKj+ecreaO+ZIQubi2OT8VJdeFlmtog6lyek6X2TP+Tr3G7kPJhRhAGH5RfAMUNA==
Address:
JtjSqJojxTAvfk55WQTvUMY0YLAYfgr6U/Ek8YrrJB2VzPD3sOxHv5NDHitgzutDs6L2ZZI6qyujWolw/wJw4R5Q72w2l0cQloHpP1AJ8qzm5JoLDflviktr3ehwkFYxIIdiUAwlzVnE09q6UuK/zJQMDwEV2tDhNn81HNEJV6YFnVpFbZKjDh/hb1bJR1wJAggCcGjX2V+X5Jq+Hw8PNzsGRbpUxr+DvNSFe8dfKiAUxCjb0J6r0nUHssUJTUx5KrOnf7h2+gLE4oGxcSEqpEOqCZG+PoTb/07oNJxssTmLdGWI4YwVn9BUdc/Oh1gkRK4GzkgFcldxT/HQPCcBTA==
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:
SY4ePxoJ+jiFRTYhseDQqUWaefk5TeDbRuOzNJHWVB4iUMT22QTv+9zMT1ONR1p5cS20xCuuHZOqAIT0JqpCrVRJR+AaLpSl9tjxWV33DcTkwtQnmqR8l+VYc55Lfx1UWlET/kTm2q+sEakLzdoaaqoL1ix+88PeQDHPfD2EYhAgu+QPUAk5iWMB8rOwvkapGPpvS5ecFSyWtrCFpXe7V77y+CrBfBPtf2eCSliWdltdw+Wwwskfo2BR/yzdGV1kkpdNl4Yjqa+2Of24s0aJ1w8b927MuY5heSRI939anrWHxFSFkn+zFLCMEkS5VDk5h0o9qgHjA+zXgd9Ubd70lQ==
I confirm that I have received and understood information provided to me on COVID-19 vaccination
WeSVI7FwEkl3FF64dKHWaHrf3eIwZMqdD08P7j7F9f44lbGDIUGGVaU7NmiGx50E6T6CwUqFEKAYU+WPlUxG6WlxcJse19RehAv2Pchn7Th9Vl7xvq8JD86YxpeTwgDuI8hKTKznUoRLvj96r9tthuXL1GCOwFlB3hXw2roi1EK3xqka/1QAFS5GeCKzO40L0cAu2Whj+sKezPQGsEjnmDJvy9dTCVTZT9GA3psR2EOqpb/2vWzJ1KVNbvwObPTmor7hS/a8oa/ESCkpd5kcCDz0WpkhNN4Izgr1spvk/HLnE7EecrCXbnyHQna86FrbSQwUP8UgZ2z2j3FNXNiEfQ==
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
ECfNpo/vhUXL8tBlUTD9FwRU64lqoGbK2jmX7roFCiI7c6QnVevdQg2+kJJ7z7Z3Z4r7yd07IdzBhKyywqm+Sv0lBcH+LACYDp4TCVJwTDt2amjrQezMQdy5gq0ZMt6ImcEbiSNFbsOvztFjAJCrHy0oGctGNmQ5GHgh6LssF6OyrT/agT29fsGWqjUjbMZVdh1nO9OGBbvx/rUS8P69RFzF38Qz2jlCoX2bBYYqaKh1CDylrkDQcMlS3o4i6+ehUr7HnoZOHqIMGReA3u3x/sXuzhzPD7TPG4fmQn/HA9lqIMiX5sCW5cVg939EHXOTSunHt0bV77kocdO0+KO0Mg==
I agree to receive a course of COVID-19 vaccine (two doses of the same vaccine)
B779NC0nj/3PiPc06J6wUYiswfN7yXD6imlj97kcllXyVMR7xu62q+OcazZ92iHDe3S1BdkN2+n3+awmK8s0ub7ropURVnFJz0DxunJJaJEn/UdVhGWHDSz2fHdMV4Td4q8dVhaR4/buZHI1jHygx6zKkfDGTIdLzHUU2uJx8vrgffU3fJvq2S0OHfY/SBaxaIGHAlBBVH89zIErom9LkEbHXZsGrddtdNQU9++fT/5hpcXNHYNNPWEf2vOw/fj7cbB+HDLuYWyyshnAHRwjs5FOpVXUi7VLwLGNUhzwQH78VobmNQSnejRyY3kruLc+rYhxjUy7OpQ8BBBl+kPumw==
Name
ZTOBA6zBToo8c/T3tQL3Aa8sdT7QKDgKR7LLKfOIBD76hr6fuH8UH+XY6CXguab7egQsT2abno2OI1dR3IlJIBfkZrogUO7AKswfSXOEKGJa0v/TMRkoa0J2XPhU5YtTHZRxZTWqzEF3zmPmvxudHyNeJuuZEdZb51K84r2Gl1YBR+uP6ecPSLz8cWknun6tprbeaLUnobrDiRJ1Do/DJbTGxMdtDiymG2zWFwK4GcAB8Yh1aiwtS2fu/ucCwBFJDYGoA/Hp/XjFNdLLofY905rWArUVTPtQ78AGiXovEXopw5/OPqkM5xCzGTScM9KI6NunbXWrl3Bc+311Xnmn7g== K7bFu06pUHTHhK6nwUDkaSXydRIhrSTrthV6X4YKQOGEhoO6XCKM22qLKJWFJzSsjgGCrYICepq+O6IijrFKd/9v1NEg8JzUvLz87KdjY9Q2IbBQI6p5std39MVDD/RG5vtMnZ90263oSxs4Uz1ecBkUAISpuSLXdw5OlCh4QO5cXcm0jjuCcbVscEAhOpXxlem71SAv3od0PjDkedJIY4zL/G9Nmjq8N0iG6Q8hLbX/Yx4g08bU+ZwW3lhFhl3FPx01FMxXlTSubKlA/HUx4s3FxD4hUzxX0lUIdo1fSUlMgbGdSs9ya5jhstEnGTbKFEApGK/2BXieaSNQTLatiQ==
Signature
Date
Invalid date
←Back to Inbox
Inbox Settings
QUESTION ALIGNMENT
Side by side
Top
LINE SPACING
Compact
Medium
Wide
DATE SETTINGS
Language
Afrikaans
Albanian
Arabic
Arabic (Algeria)
Arabic (Kuwait)
Arabic (Lybia)
Arabic (Morocco)
Arabic (Saudi Arabia)
Arabic (Tunisia)
Armenian
Azerbaijani
Bambara
Basque
Belarusian
Bengali
Bosnian
Breton
Bulgarian
Burmese
Cambodian
Catalan
Central Atlas Tamazight
Central Atlas Tamazight Latin
Chinese (China)
Chinese (Hong Kong)
Chinese (Taiwan)
Chuvash
Croatian
Czech
Danish
Dutch
Dutch (Belgium)
English (Australia)
English (Canada)
English (Ireland)
English (Israel)
English (New Zealand)
English (United Kingdom)
English (United States)
Esperanto
Estonian
Faroese
Finnish
French
French (Canada)
French (Switzerland)
Frisian
Galician
Georgian
German
German (Austria)
German (Switzerland)
Greek
Gujarati
Hebrew
Hindi
Hungarian
Icelandic
Indonesian
Italian
Japanese
Javanese
Kannada
Kazakh
Klingon
Konkani Latin script
Korean
Kyrgyz
Lao
Latvian
Lithuanian
Luxembourgish
Macedonian
Malay
Malay
Malayalam
Maldivian
Maltese (Malta)
Maori
Marathi
Mongolian
Montenegrin
Nepalese
Northern Sami
Norwegian Bokmål
Nynorsk
Persian
Polish
Portuguese
Portuguese (Brazil)
Pseudo
Punjabi (India)
Romanian
Russian
Scottish Gaelic
Serbian
Serbian Cyrillic
Sindhi
Sinhalese
Slovak
Slovenian
Spanish
Spanish (Dominican Republic)
Spanish (United States)
Swahili
Swedish
Tagalog (Philippines)
Tajik
Talossan
Tamil
Telugu
Tetun Dili (East Timor)
Thai
Tibetan
Turkish
Ukrainian
Urdu
Uyghur (China)
Uzbek
Uzbek Latin
Vietnamese
Welsh
Yoruba Nigeria
siSwati
Format
Monday, June 7, 2021 2:01 PM
June 7, 2021 2:01 PM
June 7, 2021
06/07/2021
Jun 7, 2021 2:01 PM
PRINT SETTINGS
UPDATE PRINT SETTINGS
FIELD SETTINGS
Show headers and text
Hide empty form fields
Show addresses on map
SHOW/HIDE FIELDS
HEADER SETTINGS
Select field to use as header
Submitter - Name
Name
Name
Email
Medicare Card:
Date of Birth:
Address:
Phone Contact Number :
Sex :
Next of kin (in case of emergency) Name and Contact Number:
Legal guardian/substitute decision-maker’s name:
Date
Select field to use as subheader
Submitter - Email
Name
Name
Email
Medicare Card:
Date of Birth:
Address:
Phone Contact Number :
Sex :
Next of kin (in case of emergency) Name and Contact Number:
Legal guardian/substitute decision-maker’s name:
Date
None
This will appear below the header
Hide submission header
Please wait while your document is printing.
Done
All
Read
Unread
Starred
Unstarred
Reply
Forward
Comment
Star
Mark as Unread
Edit Submission
Archive
Move to Trash
Download
Print
Customize PDF
Print version
Inbox Settings
Form
Download All
View Form
Assign Form
Edit Form
Download as CSV
Download as Excel
Download as PDF
Print version
-
Rehan Support Team LeadReplied on June 8, 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