Health Screening Appointment

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Patient's Particular

{ parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el) }} /> <${validation.ErrorMessage} errors=${validation.errors} name="name" as=${html``} />

<${props.Flatpickr} name="dob" className="mf-input mf-date-input mf-left-parent " placeholder="${ parent.decodeEntities(`Date of Birth`) } " options=${{"minDate":"","maxDate":"","dateFormat":"m-d-Y","enableTime":"","disable":[],"mode":"single","static":true,"disableMobile":true,"time_24hr":false}} value=${parent.getValue('dob')} onInput=${parent.handleDateTime} aria-invalid=${validation.errors['dob'] ? 'true' : 'false'} onReady=${(dates, dateStr, instance) => props.DateWidget( instance, '', {"message":"This field is required.","required":false}, register, parent )} /> <${validation.ErrorMessage} errors=${validation.errors} name="dob" as=${html``} />

<${props.Select} className=${"mf-input mf-input-select " + ( validation.errors['Gender'] ? 'mf-invalid' : '' )} classNamePrefix="mf_select" name="Gender" placeholder="${ parent.decodeEntities(`Select`) } " isSearchable=${false} options=${[{"label":"Gender","value":"Gender","isDisabled":false},{"label":"Male","value":"Male","isDisabled":false},{"label":"Female","value":"Female","isDisabled":false}]} value=${parent.getValue("Gender") ? [{"label":"Gender","value":"Gender","isDisabled":false},{"label":"Male","value":"Male","isDisabled":false},{"label":"Female","value":"Female","isDisabled":false}].filter(item => item.value === parent.getValue("Gender"))[0] : []} onChange=${(e)=> parent.handleSelect(e, "Gender")} ref=${() => { register("Gender", parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false})); if ( parent.getValue("Gender") === '' && false ) { parent.setValue( 'Gender', '', true ); parent.handleChange({ target: { name: 'Gender', value: '' } }); } }} /> <${validation.ErrorMessage} errors=${validation.errors} name="Gender" as=${html``} />

<${props.Select} className=${"mf-input mf-input-select " + ( validation.errors['Nationality'] ? 'mf-invalid' : '' )} classNamePrefix="mf_select" name="Nationality" placeholder="${ parent.decodeEntities(`Select`) } " isSearchable=${false} options=${[{"label":"Nationality","value":"nationality","isDisabled":false},{"label":"USA","value":"usa","isDisabled":false},{"label":"Canada","value":"canada","isDisabled":false},{"label":"United Kingdom","value":"uk","isDisabled":false},{"label":"Germany","value":"germany","isDisabled":false},{"label":"France","value":"france","isDisabled":false},{"label":"Saudi Arabia","value":"saudi arabia","isDisabled":false},{"label":"Indonesia","value":"indonesia","isDisabled":false},{"label":"Malaysia","value":"malaysia","isDisabled":false},{"label":"Netherland","value":"netherland","isDisabled":false},{"label":"Finland","value":"Finland","isDisabled":false},{"label":"Mexico","value":"mexico","isDisabled":false}]} value=${parent.getValue("Nationality") ? [{"label":"Nationality","value":"nationality","isDisabled":false},{"label":"USA","value":"usa","isDisabled":false},{"label":"Canada","value":"canada","isDisabled":false},{"label":"United Kingdom","value":"uk","isDisabled":false},{"label":"Germany","value":"germany","isDisabled":false},{"label":"France","value":"france","isDisabled":false},{"label":"Saudi Arabia","value":"saudi arabia","isDisabled":false},{"label":"Indonesia","value":"indonesia","isDisabled":false},{"label":"Malaysia","value":"malaysia","isDisabled":false},{"label":"Netherland","value":"netherland","isDisabled":false},{"label":"Finland","value":"Finland","isDisabled":false},{"label":"Mexico","value":"mexico","isDisabled":false}].filter(item => item.value === parent.getValue("Nationality"))[0] : []} onChange=${(e)=> parent.handleSelect(e, "Nationality")} ref=${() => { register("Nationality", parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false})); if ( parent.getValue("Nationality") === '' && false ) { parent.setValue( 'Nationality', '', true ); parent.handleChange({ target: { name: 'Nationality', value: '' } }); } }} /> <${validation.ErrorMessage} errors=${validation.errors} name="Nationality" as=${html``} />

parent.activateValidation({"message":"This field is required.","emailMessage":"Please enter a valid Email address","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el)} /> <${validation.ErrorMessage} errors=${validation.errors} name="mf-email" as=${html``} />

Contact Person's Particulars, If Different From Patient

Appointment Details

<${props.Select} className=${"mf-input mf-input-select " + ( validation.errors['package'] ? 'mf-invalid' : '' )} classNamePrefix="mf_select" name="package" placeholder="${ parent.decodeEntities(`Select`) } " isSearchable=${false} options=${[{"label":"Health Screening Package","value":"Screening Package","isDisabled":false},{"label":"Essential Package For Men @ $438 (Inclusive of GST)","value":"Essential Package For Men @ $438 (Inclusive of GST)","isDisabled":false},{"label":"Essential Package For Women @ $538 (Inclusive of GST)","value":"Essential Package For Women @ $538 (Inclusive of GST)","isDisabled":false},{"label":"Essential Holiday Bundle Package For Men @ $638 (Inclusive of GST)","value":"Essential Holiday Bundle Package For Men @ $638 (Inclusive of GST)","isDisabled":false},{"label":"Essential Holiday Bundle Package For Women @ $638 (Inclusive of GST)","value":"Essential Holiday Bundle Package For Men @ $638 (Inclusive of GST)","isDisabled":false}]} value=${parent.getValue("package") ? [{"label":"Health Screening Package","value":"Screening Package","isDisabled":false},{"label":"Essential Package For Men @ $438 (Inclusive of GST)","value":"Essential Package For Men @ $438 (Inclusive of GST)","isDisabled":false},{"label":"Essential Package For Women @ $538 (Inclusive of GST)","value":"Essential Package For Women @ $538 (Inclusive of GST)","isDisabled":false},{"label":"Essential Holiday Bundle Package For Men @ $638 (Inclusive of GST)","value":"Essential Holiday Bundle Package For Men @ $638 (Inclusive of GST)","isDisabled":false},{"label":"Essential Holiday Bundle Package For Women @ $638 (Inclusive of GST)","value":"Essential Holiday Bundle Package For Men @ $638 (Inclusive of GST)","isDisabled":false}].filter(item => item.value === parent.getValue("package"))[0] : []} onChange=${(e)=> parent.handleSelect(e, "package")} ref=${() => { register("package", parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false})); if ( parent.getValue("package") === '' && false ) { parent.setValue( 'package', '', true ); parent.handleChange({ target: { name: 'package', value: '' } }); } }} /> <${validation.ErrorMessage} errors=${validation.errors} name="package" as=${html``} />

<${props.Flatpickr} name="appointment_date" className="mf-input mf-date-input mf-left-parent " placeholder="${ parent.decodeEntities(`Preferred Apointment Date`) } " options=${{"minDate":"","maxDate":"","dateFormat":"m-d-Y","enableTime":"","disable":[],"mode":"single","static":true,"disableMobile":true,"time_24hr":false}} value=${parent.getValue('appointment_date')} onInput=${parent.handleDateTime} aria-invalid=${validation.errors['appointment_date'] ? 'true' : 'false'} onReady=${(dates, dateStr, instance) => props.DateWidget( instance, '', {"message":"This field is required.","required":false}, register, parent )} /> <${validation.ErrorMessage} errors=${validation.errors} name="appointment_date" as=${html``} />

<${props.Select} className=${"mf-input mf-input-select " + ( validation.errors['clinic'] ? 'mf-invalid' : '' )} classNamePrefix="mf_select" name="clinic" placeholder="${ parent.decodeEntities(`Select`) } " isSearchable=${false} options=${[{"label":"Clinic Location","value":"Executive Health Screener \u2013 Atlanta","isDisabled":false},{"label":"Executive Health Screener \u2013 Atlanta","value":"Executive Health Screener \u2013 Atlanta","isDisabled":false},{"label":"Executive Health Screener \u2013 San Francisco","value":"Executive Health Screener \u2013 San Francisco","isDisabled":false},{"label":"Executive Health Screener \u2013 New Mexico","value":"Executive Health Screener \u2013 New Mexico","isDisabled":false},{"label":"Executive Health Screener \u2013 Colorado","value":"Executive Health Screener \u2013 Colorado","isDisabled":false},{"label":"Executive Health Screener \u2013 Ohio","value":"Executive Health Screener \u2013 Ohio","isDisabled":false}]} value=${parent.getValue("clinic") ? [{"label":"Clinic Location","value":"Executive Health Screener \u2013 Atlanta","isDisabled":false},{"label":"Executive Health Screener \u2013 Atlanta","value":"Executive Health Screener \u2013 Atlanta","isDisabled":false},{"label":"Executive Health Screener \u2013 San Francisco","value":"Executive Health Screener \u2013 San Francisco","isDisabled":false},{"label":"Executive Health Screener \u2013 New Mexico","value":"Executive Health Screener \u2013 New Mexico","isDisabled":false},{"label":"Executive Health Screener \u2013 Colorado","value":"Executive Health Screener \u2013 Colorado","isDisabled":false},{"label":"Executive Health Screener \u2013 Ohio","value":"Executive Health Screener \u2013 Ohio","isDisabled":false}].filter(item => item.value === parent.getValue("clinic"))[0] : []} onChange=${(e)=> parent.handleSelect(e, "clinic")} ref=${() => { register("clinic", parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false})); if ( parent.getValue("clinic") === '' && false ) { parent.setValue( 'clinic', '', true ); parent.handleChange({ target: { name: 'clinic', value: '' } }); } }} /> <${validation.ErrorMessage} errors=${validation.errors} name="clinic" as=${html``} />

<${props.Flatpickr} name="alternative_apoointment-date" className="mf-input mf-date-input mf-left-parent " placeholder="${ parent.decodeEntities(`Alternative Appointment Date`) } " options=${{"minDate":"","maxDate":"","dateFormat":"m-d-Y","enableTime":"","disable":[],"mode":"single","static":true,"disableMobile":true,"time_24hr":false}} value=${parent.getValue('alternative_apoointment-date')} onInput=${parent.handleDateTime} aria-invalid=${validation.errors['alternative_apoointment-date'] ? 'true' : 'false'} onReady=${(dates, dateStr, instance) => props.DateWidget( instance, '', {"message":"This field is required.","required":false}, register, parent )} /> <${validation.ErrorMessage} errors=${validation.errors} name="alternative_apoointment-date" as=${html``} />

<${validation.ErrorMessage} errors=${validation.errors} name="remarks" as=${html``} />

parent.handleCheckbox(el, 'onLoad')} class="mf-checkbox multi-option-input-type" id="mf-input-checkbox-62ba70a2">

parent.handleCheckbox(el.target, 'onClick') } aria-invalid=${validation.errors['mf-checkbox'] ? 'true' : 'false'} ref=${el => { parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el)} } /> ${ parent.decodeEntities(`I agree to the terms of use and Medici's Personal Data Protection Policy and consent to the use of my personal data given above to process follow-up actions to provide a seamless patient experience, including but not limited to confirming my appointment etc.`) }

<${validation.ErrorMessage} errors=${validation.errors} name="mf-checkbox" as=${html``} />