{"id":472,"date":"2024-05-26T00:19:29","date_gmt":"2024-05-26T00:19:29","guid":{"rendered":"http:\/\/www.manorpharmacy.ie\/wordpress\/?page_id=472"},"modified":"2024-05-26T00:21:49","modified_gmt":"2024-05-26T00:21:49","slug":"vaccinesform","status":"publish","type":"page","link":"https:\/\/www.manorpharmacy.ie\/wordpress\/?page_id=472","title":{"rendered":"Vaccination Forms"},"content":{"rendered":"<div class=\"wpforms-container wpforms-container-full wpforms-block wpforms-block-6134bcd6-39cc-4e32-80fd-ac8ffb731d40\" id=\"wpforms-381\"><form id=\"wpforms-form-381\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"381\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/wordpress\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F472\" data-token=\"e178d29e5f88fb14b0faca63f1bdac38\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-field-container\"><div id=\"wpforms-381-field_15-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"15\"><label class=\"wpforms-field-label\" for=\"wpforms-381-field_15\">Choose a vaccine <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-381-field_15\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-381-field_15_1\" name=\"wpforms[fields][15]\" value=\"Flu Vaccine\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-381-field_15_1\">Flu Vaccine<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-381-field_15_2\" name=\"wpforms[fields][15]\" value=\"Covid Vaccine\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-381-field_15_2\">Covid Vaccine<\/label><\/li><\/ul><\/div><div id=\"wpforms-381-field_0-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"0\"><label class=\"wpforms-field-label\" for=\"wpforms-381-field_0\">Name <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-381-field_0\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][0][first]\" required><label for=\"wpforms-381-field_0\" class=\"wpforms-field-sublabel after \">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-381-field_0-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][0][last]\" required><label for=\"wpforms-381-field_0-last\" class=\"wpforms-field-sublabel after \">Last<\/label><\/div><\/div><\/div><div id=\"wpforms-381-field_1-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"1\"><label class=\"wpforms-field-label\" for=\"wpforms-381-field_1\">Email <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"email\" id=\"wpforms-381-field_1\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][1]\" spellcheck=\"false\" required><\/div><div id=\"wpforms-381-field_16-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"16\"><label class=\"wpforms-field-label\" for=\"wpforms-381-field_16\">Date of Birth (DD\/MM\/YYYY) <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-381-field_16\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][16]\" required><\/div><div id=\"wpforms-381-field_5-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"5\"><label class=\"wpforms-field-label\" for=\"wpforms-381-field_5\">Gender <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-381-field_5\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-381-field_5_1\" name=\"wpforms[fields][5]\" value=\"Male\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-381-field_5_1\">Male<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-381-field_5_2\" name=\"wpforms[fields][5]\" value=\"Female\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-381-field_5_2\">Female<\/label><\/li><\/ul><\/div><div id=\"wpforms-381-field_8-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"8\"><label class=\"wpforms-field-label\" for=\"wpforms-381-field_8\">Nationality <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-381-field_8\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][8]\" required><\/div><div id=\"wpforms-381-field_9-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"9\"><label class=\"wpforms-field-label\" for=\"wpforms-381-field_9\">Ethnicity <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-381-field_9\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][9]\" required><\/div><div id=\"wpforms-381-field_10-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"10\"><label class=\"wpforms-field-label\" for=\"wpforms-381-field_10\">PPS Number <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-381-field_10\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][10]\" required><\/div><div id=\"wpforms-381-field_14-container\" class=\"wpforms-field wpforms-field-number\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-381-field_14\">Irish Mobile Number  <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"number\" pattern=\"\\d*\" id=\"wpforms-381-field_14\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][14]\" required><\/div><div id=\"wpforms-381-field_12-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"12\"><label class=\"wpforms-field-label\" for=\"wpforms-381-field_12\">Address (or Eircode) <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-381-field_12\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][12]\" required><\/div><div id=\"wpforms-381-field_13-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"13\"><label class=\"wpforms-field-label\" for=\"wpforms-381-field_13\">G.P. \/ Doctor <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-381-field_13\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][13]\" required><\/div><div id=\"wpforms-381-field_19-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"19\"><label class=\"wpforms-field-label\" for=\"wpforms-381-field_19\">Email Consent <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-381-field_19\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-381-field_19_1\" name=\"wpforms[fields][19][]\" value=\"I consent to be contacted by Manor Pharmacy via email for the purposes of vaccination.\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-381-field_19_1\">I consent to be contacted by Manor Pharmacy via email for the purposes of vaccination.<\/label><\/li><\/ul><\/div><div id=\"wpforms-381-field_2-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"2\"><label class=\"wpforms-field-label\" for=\"wpforms-381-field_2\">Comment or Message<\/label><textarea id=\"wpforms-381-field_2\" class=\"wpforms-field-medium\" name=\"wpforms[fields][2]\" ><\/textarea><div class=\"wpforms-field-description\">State preferential day and time here.\r\n\r\nPlease also add if you are from a special cohort or getting the vaccine\u00a0based on age.<\/div><\/div><\/div><!-- .wpforms-field-container --><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"381\"><input type=\"hidden\" name=\"wpforms[author]\" value=\"1\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-381\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><img decoding=\"async\" loading=\"lazy\" src=\"https:\/\/www.manorpharmacy.ie\/wordpress\/wp-content\/plugins\/wpforms-lite\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/div><\/form><\/div>  <!-- .wpforms-container -->","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":[],"_links":{"self":[{"href":"https:\/\/www.manorpharmacy.ie\/wordpress\/index.php?rest_route=\/wp\/v2\/pages\/472"}],"collection":[{"href":"https:\/\/www.manorpharmacy.ie\/wordpress\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.manorpharmacy.ie\/wordpress\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.manorpharmacy.ie\/wordpress\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.manorpharmacy.ie\/wordpress\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=472"}],"version-history":[{"count":2,"href":"https:\/\/www.manorpharmacy.ie\/wordpress\/index.php?rest_route=\/wp\/v2\/pages\/472\/revisions"}],"predecessor-version":[{"id":476,"href":"https:\/\/www.manorpharmacy.ie\/wordpress\/index.php?rest_route=\/wp\/v2\/pages\/472\/revisions\/476"}],"wp:attachment":[{"href":"https:\/\/www.manorpharmacy.ie\/wordpress\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=472"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}