{"id":614,"date":"2025-05-01T11:35:21","date_gmt":"2025-05-01T08:35:21","guid":{"rendered":"https:\/\/lsm.sa\/?page_id=614"},"modified":"2025-05-01T11:39:19","modified_gmt":"2025-05-01T08:39:19","slug":"epcr-events","status":"publish","type":"page","link":"https:\/\/lsm.sa\/ar\/epcr-events\/","title":{"rendered":"ePCR-EVENTS"},"content":{"rendered":"\n<div class=\"forminator-guttenberg\"><div class=\"forminator-ui forminator-custom-form forminator-custom-form-610 forminator-design--default  forminator_ajax\" data-forminator-render=\"0\" data-form=\"forminator-module-610\" data-uid=\"6a2782b49278b\"><br\/><\/div><form\r\n\t\t\t\tid=\"forminator-module-610\"\r\n\t\t\t\tclass=\"forminator-ui forminator-custom-form forminator-custom-form-610 forminator-design--default  forminator_ajax\"\r\n\t\t\t\tmethod=\"post\"\r\n\t\t\t\tdata-forminator-render=\"0\"\r\n\t\t\t\tdata-form-id=\"610\"\r\n\t\t\t\t data-color-option=\"theme\" data-design=\"default\" data-grid=\"open\" style=\"display: none;\"\r\n\t\t\t\tdata-uid=\"6a2782b49278b\"\r\n\t\t\t><div role=\"alert\" aria-live=\"polite\" class=\"forminator-response-message forminator-error\" aria-hidden=\"true\"><\/div><div class=\"forminator-row forminator-hidden\"><div id=\"hidden-2\" class=\"forminator-field-hidden  forminator-col-12 \"><input type=\"hidden\" id=\"hidden-2_6a2782b49278b\" name=\"hidden-2\" value=\"216.73.216.140\" \/><\/div><\/div><div class=\"forminator-row forminator-hidden\"><div id=\"hidden-3\" class=\"forminator-field-hidden  forminator-col-12 \"><input type=\"hidden\" id=\"hidden-3_6a2782b49278b\" name=\"hidden-3\" value=\"6:04:20 \u0635, UTC\" \/><\/div><\/div><div class=\"forminator-row forminator-hidden\"><div id=\"hidden-1\" class=\"forminator-field-hidden  forminator-col-12 \"><input type=\"hidden\" id=\"hidden-1_6a2782b49278b\" name=\"hidden-1\" value=\"09\/06\/2026\" \/><\/div><\/div><div class=\"forminator-row\"><div id=\"select-1\" class=\"forminator-field-select forminator-col forminator-col-3 \"><div class=\"forminator-field\"><label for=\"forminator-form-610__field--select-1_6a2782b49278b\" id=\"forminator-form-610__field--select-1_6a2782b49278b-label\" class=\"forminator-label\">Medical Unit<\/label><span id=\"forminator-form-610__field--select-1_6a2782b49278b-description\" class=\"forminator-description\">Unit Code<\/span><select  id=\"forminator-form-610__field--select-1_6a2782b49278b\" class=\"forminator-select--field forminator-select2 forminator-select2-multiple\" data-required=\"\" name=\"select-1\" data-default-value=\"\" data-hidden-behavior=\"zero\" data-placeholder=\"\" data-search=\"false\" data-search-placeholder=\"\" data-checkbox=\"false\" data-allow-clear=\"false\" aria-labelledby=\"forminator-form-610__field--select-1_6a2782b49278b-label\" aria-describedby=\"forminator-form-610__field--select-1_6a2782b49278b-description\"><option value=\"MED-01\"  data-calculation=\"0\">MED-01<\/option><option value=\"MED-02\"  data-calculation=\"0\">MED-02<\/option><option value=\"MED-03\"  data-calculation=\"0\">MED-03<\/option><option value=\"MED-04\"  data-calculation=\"0\">MED-04<\/option><option value=\"MED-05\"  data-calculation=\"0\">MED-05<\/option><option value=\"MED-06\"  data-calculation=\"0\">MED-06<\/option><option value=\"MED-07\"  data-calculation=\"0\">MED-07<\/option><option value=\"MED-08\"  data-calculation=\"0\">MED-08<\/option><option value=\"MED-09\"  data-calculation=\"0\">MED-09<\/option><option value=\"MED-10\"  data-calculation=\"0\">MED-10<\/option><option value=\"MED-11\"  data-calculation=\"0\">MED-11<\/option><option value=\"MED-12\"  data-calculation=\"0\">MED-12<\/option><option value=\"MED-13\"  data-calculation=\"0\">MED-13<\/option><option value=\"MED-14\"  data-calculation=\"0\">MED-14<\/option><option value=\"MED-15\"  data-calculation=\"0\">MED-15<\/option><option value=\"MED-16\"  data-calculation=\"0\">MED-16<\/option><option value=\"MED-17\"  data-calculation=\"0\">MED-17<\/option><option value=\"MED-18\"  data-calculation=\"0\">MED-18<\/option><option value=\"MED-19\"  data-calculation=\"0\">MED-19<\/option><option value=\"MED-20\"  data-calculation=\"0\">MED-20<\/option><option value=\"MED-21\"  data-calculation=\"0\">MED-21<\/option><option value=\"MED-22\"  data-calculation=\"0\">MED-22<\/option><option value=\"MED-23\"  data-calculation=\"0\">MED-23<\/option><option value=\"MED-24\"  data-calculation=\"0\">MED-24<\/option><option value=\"MED-25\"  data-calculation=\"0\">MED-25<\/option><option value=\"MED-26\"  data-calculation=\"0\">MED-26<\/option><option value=\"MED-27\"  data-calculation=\"0\">MED-27<\/option><option value=\"MED-28\"  data-calculation=\"0\">MED-28<\/option><option value=\"MED-29\"  data-calculation=\"0\">MED-29<\/option><option value=\"MED-30\"  data-calculation=\"0\">MED-30<\/option><option value=\"MED-31\"  data-calculation=\"0\">MED-31<\/option><option value=\"MED-32\"  data-calculation=\"0\">MED-32<\/option><option value=\"MED-33\"  data-calculation=\"0\">MED-33<\/option><option value=\"MED-34\"  data-calculation=\"0\">MED-34<\/option><option value=\"MED-35\"  data-calculation=\"0\">MED-35<\/option><option value=\"MED-36\"  data-calculation=\"0\">MED-36<\/option><option value=\"MED-37\"  data-calculation=\"0\">MED-37<\/option><option value=\"MED-38\"  data-calculation=\"0\">MED-38<\/option><option value=\"MED-39\"  data-calculation=\"0\">MED-39<\/option><option value=\"MED-40\"  data-calculation=\"0\">MED-40<\/option><option value=\"R-01\"  data-calculation=\"0\">R-01<\/option><option value=\"R-02\"  data-calculation=\"0\">R-02<\/option><option value=\"R-03\"  data-calculation=\"0\">R-03<\/option><option value=\"R-04\"  data-calculation=\"0\">R-04<\/option><option value=\"R-05\"  data-calculation=\"0\">R-05<\/option><option value=\"R-06\"  data-calculation=\"0\">R-06<\/option><option value=\"R-07\"  data-calculation=\"0\">R-07<\/option><option value=\"R-08\"  data-calculation=\"0\">R-08<\/option><option value=\"R-09\"  data-calculation=\"0\">R-09<\/option><option value=\"R-10\"  data-calculation=\"0\">R-10<\/option><option value=\"R-11\"  data-calculation=\"0\">R-11<\/option><option value=\"R-12\"  data-calculation=\"0\">R-12<\/option><option value=\"R-13\"  data-calculation=\"0\">R-13<\/option><option value=\"R-14\"  data-calculation=\"0\">R-14<\/option><option value=\"R-15\"  data-calculation=\"0\">R-15<\/option><option value=\"R-16\"  data-calculation=\"0\">R-16<\/option><option value=\"R-17\"  data-calculation=\"0\">R-17<\/option><option value=\"R-18\"  data-calculation=\"0\">R-18<\/option><option value=\"R-19\"  data-calculation=\"0\">R-19<\/option><option value=\"R-20\"  data-calculation=\"0\">R-20<\/option><option value=\"R-21\"  data-calculation=\"0\">R-21<\/option><option value=\"R-22\"  data-calculation=\"0\">R-22<\/option><option value=\"R-23\"  data-calculation=\"0\">R-23<\/option><option value=\"R-24\"  data-calculation=\"0\">R-24<\/option><option value=\"R-25\"  data-calculation=\"0\">R-25<\/option><option value=\"R-26\"  data-calculation=\"0\">R-26<\/option><option value=\"R-27\"  data-calculation=\"0\">R-27<\/option><option value=\"R-28\"  data-calculation=\"0\">R-28<\/option><option value=\"R-29\"  data-calculation=\"0\">R-29<\/option><option value=\"R-30\"  data-calculation=\"0\">R-30<\/option><option value=\"R-31\"  data-calculation=\"0\">R-31<\/option><option value=\"R-32\"  data-calculation=\"0\">R-32<\/option><option value=\"R-33\"  data-calculation=\"0\">R-33<\/option><option value=\"R-34\"  data-calculation=\"0\">R-34<\/option><option value=\"R-35\"  data-calculation=\"0\">R-35<\/option><option value=\"R-36\"  data-calculation=\"0\">R-36<\/option><option value=\"R-37\"  data-calculation=\"0\">R-37<\/option><option value=\"R-38\"  data-calculation=\"0\">R-38<\/option><option value=\"R-39\"  data-calculation=\"0\">R-39<\/option><option value=\"R-40\"  data-calculation=\"0\">R-40<\/option><option value=\"R-41\"  data-calculation=\"0\">R-41<\/option><option value=\"R-42\"  data-calculation=\"0\">R-42<\/option><option value=\"R-43\"  data-calculation=\"0\">R-43<\/option><option value=\"R-44\"  data-calculation=\"0\">R-44<\/option><option value=\"R-45\"  data-calculation=\"0\">R-45<\/option><option value=\"R-46\"  data-calculation=\"0\">R-46<\/option><option value=\"R-47\"  data-calculation=\"0\">R-47<\/option><option value=\"R-48\"  data-calculation=\"0\">R-48<\/option><option value=\"R-49\"  data-calculation=\"0\">R-49<\/option><option value=\"R-50\"  data-calculation=\"0\">R-50<\/option><option value=\"Clinic-01\"  data-calculation=\"0\">Clinic-01<\/option><option value=\"Clinic-02\"  data-calculation=\"0\">Clinic-02<\/option><option value=\"Clinic-03\"  data-calculation=\"0\">Clinic-03<\/option><option value=\"Clinic-04\"  data-calculation=\"0\">Clinic-04<\/option><option value=\"Clinic-05\"  data-calculation=\"0\">Clinic-05<\/option><option value=\"Clinic-06\"  data-calculation=\"0\">Clinic-06<\/option><option value=\"Clinic-07\"  data-calculation=\"0\">Clinic-07<\/option><option value=\"Clinic-08\"  data-calculation=\"0\">Clinic-08<\/option><option value=\"Clinic-09\"  data-calculation=\"0\">Clinic-09<\/option><option value=\"Clinic-10\"  data-calculation=\"0\">Clinic-10<\/option><option value=\"Clinic-11\"  data-calculation=\"0\">Clinic-11<\/option><option value=\"Clinic-12\"  data-calculation=\"0\">Clinic-12<\/option><option value=\"Clinic-13\"  data-calculation=\"0\">Clinic-13<\/option><option value=\"Clinic-14\"  data-calculation=\"0\">Clinic-14<\/option><option value=\"Clinic-15\"  data-calculation=\"0\">Clinic-15<\/option><\/select><\/div><\/div><div id=\"select-2\" class=\"forminator-field-select forminator-col forminator-col-3 \"><div class=\"forminator-field\"><label for=\"forminator-form-610__field--select-2_6a2782b49278b\" id=\"forminator-form-610__field--select-2_6a2782b49278b-label\" class=\"forminator-label\">Region<\/label><span id=\"forminator-form-610__field--select-2_6a2782b49278b-description\" class=\"forminator-description\">Clinical Region Location\/Code<\/span><select  id=\"forminator-form-610__field--select-2_6a2782b49278b\" class=\"forminator-select--field forminator-select2 forminator-select2-multiple\" data-required=\"\" name=\"select-2\" data-default-value=\"\" data-hidden-behavior=\"zero\" data-placeholder=\"Select a Region\" data-search=\"false\" data-search-placeholder=\"Select a Region\" data-checkbox=\"false\" data-allow-clear=\"false\" aria-labelledby=\"forminator-form-610__field--select-2_6a2782b49278b-label\" aria-describedby=\"forminator-form-610__field--select-2_6a2782b49278b-description\"><option value=\"\"  >Select a Region<\/option><option value=\"RUH\"  data-calculation=\"0\">Riyadh Region [Al-Riyadh]<\/option><option value=\"MKA\"  data-calculation=\"0\">Makkah Region [Makkah Al-Mukarramah]<\/option><option value=\"EP\"  data-calculation=\"0\">Eastern Region [Ash-Sharqiyah]<\/option><option value=\"MED\"  data-calculation=\"0\">Medina Region [Al-Madinah Al-Munawwarah]<\/option><option value=\"ASR\"  data-calculation=\"0\">Asir Region [Asir]<\/option><option value=\"TBK\"  data-calculation=\"0\">Tabuk Region [Tabuk]<\/option><option value=\"QAS\"  data-calculation=\"0\">Qassim Region [Al-Qassim]<\/option><option value=\"JAZ\"  data-calculation=\"0\">Jazan Region [Jazan]<\/option><option value=\"NAJ\"  data-calculation=\"0\">Najran Region [Najran]<\/option><option value=\"HAIL\"  data-calculation=\"0\">Hail Region [Hail]<\/option><option value=\"AJF\"  data-calculation=\"0\">Al-Jawf Region [Al-Jawf]<\/option><option value=\"NB\"  data-calculation=\"0\">Northern Borders Region [Al-Hudud Ash-Shamaliyah]<\/option><option value=\"BAH\"  data-calculation=\"0\">Al-Baha Region [Al-Baha]<\/option><\/select><\/div><\/div><div id=\"select-9\" class=\"forminator-field-select forminator-col forminator-col-3 \"><div class=\"forminator-field\"><label for=\"forminator-form-610__field--select-9_6a2782b49278b\" id=\"forminator-form-610__field--select-9_6a2782b49278b-label\" class=\"forminator-label\">EVENT \/ SITE Name <span class=\"forminator-required\">*<\/span><\/label><span id=\"forminator-form-610__field--select-9_6a2782b49278b-description\" class=\"forminator-description\">\u0627\u0633\u0645 \u0627\u0644\u0641\u0639\u0627\u0644\u064a\u0629 \/ \u0645\u0648\u0642\u0639 \u0627\u0644\u062a\u0645\u0631\u0643\u0632<\/span><select  id=\"forminator-form-610__field--select-9_6a2782b49278b\" class=\"forminator-select--field forminator-select2 forminator-select2-multiple\" data-required=\"1\" name=\"select-9\" data-default-value=\"\" data-hidden-behavior=\"zero\" data-placeholder=\"EVENT \/ SITE Name\" data-search=\"false\" data-search-placeholder=\"EVENT \/ SITE Name\" data-checkbox=\"false\" data-allow-clear=\"false\" aria-labelledby=\"forminator-form-610__field--select-9_6a2782b49278b-label\" aria-describedby=\"forminator-form-610__field--select-9_6a2782b49278b-description\"><option value=\"\"  >EVENT \/ SITE Name<\/option><option value=\"two\"  data-calculation=\"0\">Other<\/option><\/select><\/div><\/div><div id=\"text-7\" class=\"forminator-field-text forminator-col forminator-col-3 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-7_6a2782b49278b\" id=\"forminator-field-text-7_6a2782b49278b-label\" class=\"forminator-label\">EVENT \/ SITE Name <span class=\"forminator-required\">*<\/span><\/label><span id=\"forminator-field-text-7_6a2782b49278b-description\" class=\"forminator-description\">\u0627\u0633\u0645 \u0627\u0644\u0641\u0639\u0627\u0644\u064a\u0629 \/ \u0645\u0648\u0642\u0639 \u0627\u0644\u062a\u0645\u0631\u0643\u0632<\/span><input type=\"text\" name=\"text-7\" value=\"\" placeholder=\"\" id=\"forminator-field-text-7_6a2782b49278b\" class=\"forminator-input forminator-name--field\" data-required=\"1\" aria-describedby=\"forminator-field-text-7_6a2782b49278b-description\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"time-1\" class=\"forminator-field-time forminator-col forminator-col-6 \"><label for=\"forminator-field-time-1\" id=\"forminator-field-time-1-label\" class=\"forminator-label\">Time of Call<\/label><div class=\"forminator-timepicker\" ><div class=\"forminator-row\" data-multiple=\"true\"><div id=\"time-1-hours\" class=\"forminator-col forminator-col-4\"><div class=\"forminator-field\"><label for=\"forminator-field-time-1-hours_6a2782b49278b\" id=\"forminator-field-time-1-hours_6a2782b49278b-label\" class=\"forminator-label\">Hours<\/label><input type=\"number\" name=\"time-1-hours\" min=\"0\" max=\"12\" placeholder=\"E.g. 08\" id=\"forminator-field-time-1-hours_6a2782b49278b\" class=\"forminator-input time-hours \" data-field=\"hours\" value=\"\" \/><\/div><\/div><div id=\"time-1-minutes\" class=\"forminator-col forminator-col-4\"><div class=\"forminator-field\"><label for=\"forminator-field-time-1-minutes_6a2782b49278b\" id=\"forminator-field-time-1-minutes_6a2782b49278b-label\" class=\"forminator-label\">Minutes<\/label><input type=\"number\" min=\"0\" max=\"59\" name=\"time-1-minutes\" placeholder=\"E.g. 00\" id=\"forminator-field-time-1-minutes_6a2782b49278b\" class=\"forminator-input time-minutes \" data-field=\"minutes\" value=\"\" \/><\/div><\/div><div id=\"time-1-ampm\" class=\"forminator-col forminator-col-4\"><div class=\"forminator-field\"><label for=\"forminator-field-610__field--time-1-ampm_6a2782b49278b\" id=\"forminator-field-610__field--time-1-ampm_6a2782b49278b-label\" class=\"forminator-label\">AM\/PM<\/label><select name=\"time-1-ampm\" id=\"forminator-field-610__field--time-1-ampm_6a2782b49278b\" class=\"forminator-select2 time-ampm \" data-field=\"ampm\" aria-labelledby=\"forminator-field-610__field--time-1-ampm_6a2782b49278b-label\" data-default-value=\"\"><option value=\"am\" >AM<\/option><option value=\"pm\" >PM<\/option><\/select><\/div><\/div><\/div><\/div><\/div><div id=\"select-3\" class=\"forminator-field-select forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-form-610__field--select-3_6a2782b49278b\" id=\"forminator-form-610__field--select-3_6a2782b49278b-label\" class=\"forminator-label\">Incident Type<\/label><span id=\"forminator-form-610__field--select-3_6a2782b49278b-description\" class=\"forminator-description\">Select<\/span><select  id=\"forminator-form-610__field--select-3_6a2782b49278b\" class=\"forminator-select--field forminator-select2 forminator-select2-multiple\" data-required=\"\" name=\"select-3\" data-default-value=\"\" data-hidden-behavior=\"zero\" data-placeholder=\"Select Incident Type\" data-search=\"false\" data-search-placeholder=\"Select Incident Type\" data-checkbox=\"false\" data-allow-clear=\"false\" aria-labelledby=\"forminator-form-610__field--select-3_6a2782b49278b-label\" aria-describedby=\"forminator-form-610__field--select-3_6a2782b49278b-description\"><option value=\"\"  >Select Incident Type<\/option><option value=\"1\"  data-calculation=\"0\">1 | Abdominal pain\/problems | \u0623\u0644\u0645 \/ \u0645\u0634\u0627\u0643\u0644 \u0641\u064a \u0627\u0644\u0628\u0637\u0646<\/option><option value=\"2\"  data-calculation=\"0\">2 | Allergy\/bite poisoning | \u062d\u0633\u0627\u0633\u064a\u0629\/\u062a\u0633\u0645\u0645 (\u0644\u062f\u063a\u0629\u060c \u0639\u0636\u0629)<\/option><option value=\"3\"  data-calculation=\"0\">3 | Animal bite attack | \u0647\u062c\u0648\u0645 \u0639\u0636\u0629 \u062d\u064a\u0648\u0627\u0646<\/option><option value=\"4\"  data-calculation=\"0\">4 | Assault \/ Sexual Assault \/ Taser | \u0627\u0639\u062a\u062f\u0627\u0621\/ \u0627\u0639\u062a\u062f\u0627\u0621 \u062c\u0646\u0633\u064a\/ \u0645\u0633\u062f\u0633 \u0627\u0644\u0635\u0639\u0642\u0629 \u0627\u0644\u0643\u0647\u0631\u0628\u0627\u0626\u064a\u0629<\/option><option value=\"5\"  data-calculation=\"0\">5 | Back pain (not related to an injury or recent injury) | \u0623\u0644\u0645 \u0627\u0644\u0638\u0647\u0631 (\u063a\u064a\u0631 \u0645\u0631\u062a\u0628\u0637 \u0628\u0625\u0635\u0627\u0628\u0629 \u0623\u0648 \u0625\u0635\u0627\u0628\u0629 \u0644\u0645 \u062a\u062d\u062f\u062b \u0645\u0624\u062e\u0631\u0627)<\/option><option value=\"6\"  data-calculation=\"0\">6 | breathing problems | \u0645\u0634\u0627\u0643\u0644 \u0628\u0627\u0644\u062a\u0646\u0641\u0633<\/option><option value=\"7\"  data-calculation=\"0\">7 | Burns (hot water burns) \/ Explosion (blasting) | \u062d\u0631\u0648\u0642 ( \u062d\u0631\u0648\u0642 \u0628\u0627\u0644\u0645\u0627\u0621 \u0627\u0644\u0633\u0627\u062e\u0646) \/ \u0627\u0646\u0641\u062c\u0627\u0631 (\u0646\u0633\u0641)<\/option><option value=\"8\"  data-calculation=\"0\">8 | Carbon monoxide \/ Inhalation \/ Hazardous materials \/ Chemicals \/ Organic materials \/ Radioactive materials \/ Nuclear materials | \u0623\u0648\u0644 \u0623\u0643\u0633\u064a\u062f \u0627\u0644\u0643\u0631\u0628\u0648\u0646 \/ \u0627\u0633\u062a\u0646\u0634\u0627\u0642 \/ \u0645\u0648\u0627\u062f \u062e\u0637\u0631\u0629 \/ \u0643\u064a\u0645\u0627\u0648\u064a\u0627\u062a \/ \u0645\u0648\u0627\u062f \u0639\u0636\u0648\u064a\u0629 \/ \u0645\u0648\u0627\u062f \u0645\u0634\u0639\u0629 \/ \u0645\u0648\u0627\u062f \u0646\u0648\u0648\u064a\u0629<\/option><option value=\"9\"  data-calculation=\"0\">9 | Cardiac or respiratory arrest\/death | \u062a\u0648\u0642\u0641 \u0641\u064a \u0627\u0644\u0642\u0644\u0628 \u0627\u0648 \u0627\u0644\u062a\u0646\u0641\u0633 \/ \u0645\u0648\u062a<\/option><option value=\"10\"  data-calculation=\"0\">10 | Chest pain\/chest tightness (not related to injury) | \u0623\u0644\u0645 \u0627\u0644\u0635\u062f\u0631 \/ \u0636\u064a\u0642 \u0627\u0644\u0635\u062f\u0631 (\u063a\u064a\u0631 \u0645\u0631\u062a\u0628\u0637 \u0628\u0625\u0635\u0627\u0628\u0629)<\/option><option value=\"11\"  data-calculation=\"0\">11 | suffocation | \u0627\u062e\u062a\u0646\u0627\u0642<\/option><option value=\"12\"  data-calculation=\"0\">12 | Convulsions\/Seizures | \u062a\u0634\u0646\u062c\u0627\u062a \/ \u0646\u0648\u0628\u0629 \u0645\u0631\u0636\u064a\u0629<\/option><option value=\"13\"  data-calculation=\"0\">13 | Diabetes problems | \u0645\u0634\u0627\u0643\u0644 \u0645\u0631\u0636 \u0627\u0644\u0633\u0643\u0631\u064a<\/option><option value=\"14\"  data-calculation=\"0\">14 | Drowned \/ About to drown \/ Dive \/ Diving accident | \u063a\u0631\u0642 \/ \u0639\u0644\u0649 \u0648\u0634\u0643 \u0627\u0644\u063a\u0631\u0642 \/ \u063a\u0637\u0633 \/ \u062d\u0627\u062f\u062b\u0629 \u063a\u0648\u0635<\/option><option value=\"15\"  data-calculation=\"0\">15 | electrocution\/lightning | \u0635\u0639\u0642 \u0628\u0627\u0644\u0643\u0647\u0631\u0628\u0627\u0621 \/ \u0635\u0639\u0642 \u0628\u0627\u0644\u0628\u0631\u0642<\/option><option value=\"16\"  data-calculation=\"0\">16 | Eye Problems\/Injuries | \u0645\u0634\u0627\u0643\u0644 \/ \u0625\u0635\u0627\u0628\u0627\u062a \u0627\u0644\u0639\u064a\u0646<\/option><option value=\"17\"  data-calculation=\"0\">17 | Fall | \u0633\u0642\u0648\u0637<\/option><option value=\"18\"  data-calculation=\"0\">18 | Headache | \u0635\u062f\u0627\u0639<\/option><option value=\"19\"  data-calculation=\"0\">19 | Heart Problems \/ ICD | \u0645\u0634\u0627\u0643\u0644 \u0628\u0627\u0644\u0642\u0644\u0628 \/ \u0648\u062d\u062f\u0629 \u0625\u0646\u0639\u0627\u0634 \u0642\u0644\u0628 \u0645\u0632\u0631\u0648\u0639\u0629<\/option><option value=\"20\"  data-calculation=\"0\">20 | Exposure to extreme heat\/cold | \u062a\u0639\u0631\u0636 \u0644\u062d\u0631\u0627\u0631\u0629 \/ \u0628\u0631\u0648\u062f\u0629 \u0634\u062f\u064a\u062f\u0629<\/option><option value=\"21\"  data-calculation=\"0\">21 | Bleeding\/Rupture | \u0646\u0632\u064a\u0641 \/ \u062a\u0645\u0632\u0642<\/option><option value=\"22\"  data-calculation=\"0\">22 | Unreachable\/Other Crash (Non-Traffic) | \u062d\u0627\u062f\u062b\u0629 \u0644\u0627 \u064a\u0645\u0643\u0646 \u0627\u0644\u0648\u0635\u0648\u0644 \u0625\u0644\u064a\u0647\u0627 \/ \u062d\u0634\u0631 \u0622\u062e\u0631 (\u063a\u064a\u0631 \u0645\u0631\u0648\u0631\u064a)<\/option><option value=\"23\"  data-calculation=\"0\">23 | Overdose\/Poisoning (Swallowing) | \u062c\u0631\u0639\u0629 \u0632\u0627\u0626\u062f\u0629 \/ \u062a\u0633\u0645\u0645 (\u0627\u0628\u062a\u0644\u0627\u0639)<\/option><option value=\"24\"  data-calculation=\"0\">24 | Pregnancy \/ Birth \/ Miscarriage | \u062d\u0645\u0644 \/ \u0648\u0644\u0627\u062f\u0629 \/ \u0641\u0642\u062f\u0627\u0646 \u0627\u0644\u062c\u0646\u064a\u0646<\/option><option value=\"25\"  data-calculation=\"0\">25 | Mental Illness \/ Unusual Behavior \/ Suicide Attempt | \u0645\u0631\u064a\u0636 \u0646\u0641\u0633\u064a \/ \u0633\u0644\u0648\u0643 \u063a\u064a\u0631 \u0639\u0627\u062f\u064a \/ \u0645\u062d\u0627\u0648\u0644\u0629 \u0627\u0646\u062a\u062d\u0627\u0631<\/option><option value=\"26\"  data-calculation=\"0\">26 | Sick person (specific diagnosis) | \u0634\u062e\u0635 \u0645\u0631\u064a\u0636 (\u062a\u0634\u062e\u064a\u0635 \u0645\u062d\u062f\u062f)<\/option><option value=\"27\"  data-calculation=\"0\">27 | Stabbing \/ Gunshot wound \/ Injury resulting from penetration of the human body by an instrument | \u0637\u0639\u0646 \u0628\u0633\u0643\u064a\u0646 \/ \u0625\u0635\u0627\u0628\u0629 \u0628\u0637\u0644\u0642 \u0646\u0627\u0631\u064a \/ \u0625\u0635\u0627\u0628\u0629 \u0646\u0627\u062a\u062c\u0629 \u0639\u0646 \u0627\u062e\u062a\u0631\u0627\u0642 \u0623\u062f\u0627\u0629 \u0644\u062c\u0633\u0645 \u0627\u0644\u0625\u0646\u0633\u0627\u0646<\/option><option value=\"28\"  data-calculation=\"0\">28 | (TIA) Transient ischemic attack\/stroke | (TIA) \u0633\u0643\u062a\u0629 \u062f\u0645\u0627\u063a\u064a\u0629 \/ \u0646\u0648\u0628\u0629 \u062f\u0645\u0627\u063a\u064a\u0629 \u0639\u0627\u0628\u0631\u0629<\/option><option value=\"29\"  data-calculation=\"0\">29 | Traffic Collisions \/ Transport Accidents | \u062a\u0635\u0627\u062f\u0645 \u0645\u0631\u0648\u0631\u064a \/ \u062d\u0627\u062f\u062b\u0629 \u0645\u0648\u0627\u0635\u0644\u0627\u062a<\/option><option value=\"30\"  data-calculation=\"0\">30 | Injuries (specific) | \u0625\u0635\u0627\u0628\u0627\u062a (\u0645\u062d\u062f\u062f\u0629)<\/option><option value=\"31\"  data-calculation=\"0\">31 | Fainting\/near fainting | \u063a\u064a\u0627\u0628 \u0639\u0646 \u0627\u0644\u0648\u0639\u064a \/ \u0625\u063a\u0645\u0627\u0621 \u0639\u0644\u0649 \u0648\u0634\u0643<\/option><option value=\"32\"  data-calculation=\"0\">32 | Unknown Problem (Infected Person) | \u0645\u0634\u0643\u0644\u0629 \u063a\u064a\u0631 \u0645\u0639\u0631\u0648\u0641\u0629 (\u0634\u062e\u0635 \u0645\u0635\u0627\u0628)<\/option><option value=\"33\"  data-calculation=\"0\">33 | Transfer \/ Transfer to a different department \/ Medical care for pain relief | \u0627\u0646\u062a\u0642\u0627\u0644 \/ \u062a\u062d\u0648\u064a\u0644 \u0627\u0644\u0649 \u0642\u0633\u0645 \u0645\u062e\u062a\u0644\u0641 \/ \u0639\u0646\u0627\u064a\u0629 \u0637\u0628\u064a\u0629 \u0644\u062a\u062e\u0641\u064a\u0641 \u0627\u0644\u0623\u0644\u0645<\/option><option value=\"34\"  data-calculation=\"0\">34 | CAN Collision Automatic Notification | CAN \u0625\u0646\u0630\u0627\u0631 \u062a\u0644\u0642\u0627\u0626\u064a \u0644\u0644\u0627\u0635\u0637\u062f\u0627\u0645<\/option><option value=\"36\"  data-calculation=\"0\">36 | Pandemic\/Outbreak | \u062c\u0627\u0646\u062d\u0629 \/ \u0648\u0628\u0627\u0621 \/ \u062a\u0641\u0634\u064a \u0645\u0631\u0627\u0642\u0628\u0629 \u0627\u0648 \u0641\u0631\u0632<\/option><option value=\"37\"  data-calculation=\"0\">37 | Reviews\/Transfer Between Two Hospitals | \u062a\u0642\u064a\u064a\u0645 \/ \u062a\u062d\u0648\u064a\u0644 \u0645\u0627 \u0628\u064a\u0646 \u0645\u0633\u062a\u0634\u0641\u064a\u064a\u0646<\/option><option value=\"38\"  data-calculation=\"0\">38 | Secondary Hazard Protocol (Miranda Medical Card) | \u0628\u0631\u0648\u062a\u0648\u0643\u0648\u0644 \u0627\u0644\u0623\u062e\u0637\u0627\u0631 \u0627\u0644\u062b\u0627\u0646\u0648\u064a (\u0628\u0637\u0627\u0642\u0629 \u0645\u064a\u0631\u0627\u0646\u062f\u0627 \u0627\u0644\u0637\u0628\u064a)<\/option><option value=\"39\"  data-calculation=\"0\">39 | Active Aggressors (Shooter) | \u0645\u0639\u062a\u062f\u064a \u0641\u0639\u0627\u0644 (\u0631\u0627\u0645\u064a)<\/option><option value=\"45\"  data-calculation=\"0\">45 | Unscheduled Transfers to Higher Specialized Care | \u0646\u0642\u0644 \u0644\u0631\u0639\u0627\u064a\u0629 \u0623\u0639\u0644\u0649 \u0645\u062a\u062e\u0635\u0635\u0629 \u0648\u063a\u064a\u0631 \u0645\u062c\u062f\u0648\u0644\u0629<\/option><option value=\"46\"  data-calculation=\"0\">46 | scheduled transfers between two hospitals (routine) | \u062a\u062d\u0648\u064a\u0644 \u0645\u062c\u062f\u0648\u0644 \u0628\u064a\u0646 \u0645\u0633\u062a\u0634\u0641\u064a\u064a\u0646 (\u0631\u0648\u062a\u064a\u0646\u064a)<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-1\" class=\"forminator-field-name forminator-col forminator-col-3 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-1_6a2782b49278b\" id=\"forminator-field-name-1_6a2782b49278b-label\" class=\"forminator-label\">Name<\/label><input type=\"text\" name=\"name-1\" value=\"\" placeholder=\"\u0627\u0644\u0627\u0633\u0645 \u0627\u0644\u062b\u0644\u0627\u062b\u064a\" id=\"forminator-field-name-1_6a2782b49278b\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" autocomplete=\"name\" \/><\/div><\/div><div id=\"radio-1\" class=\"forminator-field-radio forminator-col forminator-col-3 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-1-6a2782b49278b-label\"><span id=\"forminator-radiogroup-radio-1-6a2782b49278b-label\" class=\"forminator-label\">Gender<\/span><label id=\"forminator-field-radio-1-label-1\" for=\"forminator-field-radio-1-1-6a2782b49278b\" class=\"forminator-radio\" title=\"Male\"><input type=\"radio\" name=\"radio-1\" value=\"one\" id=\"forminator-field-radio-1-1-6a2782b49278b\" aria-labelledby=\"forminator-field-radio-1-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Male<\/span><\/label><label id=\"forminator-field-radio-1-label-2\" for=\"forminator-field-radio-1-2-6a2782b49278b\" class=\"forminator-radio\" title=\"Female\"><input type=\"radio\" name=\"radio-1\" value=\"two\" id=\"forminator-field-radio-1-2-6a2782b49278b\" aria-labelledby=\"forminator-field-radio-1-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Female<\/span><\/label><\/div><\/div><div id=\"text-6\" class=\"forminator-field-text forminator-col forminator-col-3 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-6_6a2782b49278b\" id=\"forminator-field-text-6_6a2782b49278b-label\" class=\"forminator-label\">Age<\/label><input type=\"text\" name=\"text-6\" value=\"\" placeholder=\"E.g. 30 Y.O.\" id=\"forminator-field-text-6_6a2782b49278b\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"select-4\" class=\"forminator-field-select forminator-col forminator-col-3 \"><div class=\"forminator-field\"><label for=\"forminator-form-610__field--select-4_6a2782b49278b\" id=\"forminator-form-610__field--select-4_6a2782b49278b-label\" class=\"forminator-label\">Nationality<\/label><select  id=\"forminator-form-610__field--select-4_6a2782b49278b\" class=\"forminator-select--field forminator-select2 forminator-select2-multiple\" data-required=\"\" name=\"select-4\" data-default-value=\"Saudi Arabia\" data-hidden-behavior=\"zero\" data-placeholder=\"Select Nationality\" data-search=\"false\" data-search-placeholder=\"Select Nationality\" data-checkbox=\"false\" data-allow-clear=\"false\" aria-labelledby=\"forminator-form-610__field--select-4_6a2782b49278b-label\"><option value=\"\"  >Select Nationality<\/option><option value=\"Afghanistan\"  data-calculation=\"0\">Afghanistan<\/option><option value=\"\u00c5land Islands\"  data-calculation=\"0\">\u00c5land Islands<\/option><option value=\"Albania\"  data-calculation=\"0\">Albania<\/option><option value=\"Algeria\"  data-calculation=\"0\">Algeria<\/option><option value=\"American Samoa\"  data-calculation=\"0\">American Samoa<\/option><option value=\"Andorra\"  data-calculation=\"0\">Andorra<\/option><option value=\"Angola\"  data-calculation=\"0\">Angola<\/option><option value=\"Anguilla\"  data-calculation=\"0\">Anguilla<\/option><option value=\"Antarctica\"  data-calculation=\"0\">Antarctica<\/option><option value=\"Antigua and Barbuda\"  data-calculation=\"0\">Antigua and Barbuda<\/option><option value=\"Argentina\"  data-calculation=\"0\">Argentina<\/option><option value=\"Armenia\"  data-calculation=\"0\">Armenia<\/option><option value=\"Aruba\"  data-calculation=\"0\">Aruba<\/option><option value=\"Australia\"  data-calculation=\"0\">Australia<\/option><option value=\"Austria\"  data-calculation=\"0\">Austria<\/option><option value=\"Azerbaijan\"  data-calculation=\"0\">Azerbaijan<\/option><option value=\"Bahamas\"  data-calculation=\"0\">Bahamas<\/option><option value=\"Bahrain\"  data-calculation=\"0\">Bahrain<\/option><option value=\"Bangladesh\"  data-calculation=\"0\">Bangladesh<\/option><option value=\"Barbados\"  data-calculation=\"0\">Barbados<\/option><option value=\"Belarus\"  data-calculation=\"0\">Belarus<\/option><option value=\"Belgium\"  data-calculation=\"0\">Belgium<\/option><option value=\"Belize\"  data-calculation=\"0\">Belize<\/option><option value=\"Benin\"  data-calculation=\"0\">Benin<\/option><option value=\"Bermuda\"  data-calculation=\"0\">Bermuda<\/option><option value=\"Bhutan\"  data-calculation=\"0\">Bhutan<\/option><option value=\"Bolivia\"  data-calculation=\"0\">Bolivia<\/option><option value=\"Bonaire, Sint Eustatius and Saba\"  data-calculation=\"0\">Bonaire, Sint Eustatius and Saba<\/option><option value=\"Bosnia and Herzegovina\"  data-calculation=\"0\">Bosnia and Herzegovina<\/option><option value=\"Botswana\"  data-calculation=\"0\">Botswana<\/option><option value=\"Bouvet Island\"  data-calculation=\"0\">Bouvet Island<\/option><option value=\"Brazil\"  data-calculation=\"0\">Brazil<\/option><option value=\"British Indian Ocean Territory\"  data-calculation=\"0\">British Indian Ocean Territory<\/option><option value=\"Brunei Darussalam\"  data-calculation=\"0\">Brunei Darussalam<\/option><option value=\"Bulgaria\"  data-calculation=\"0\">Bulgaria<\/option><option value=\"Burkina Faso\"  data-calculation=\"0\">Burkina Faso<\/option><option value=\"Burundi\"  data-calculation=\"0\">Burundi<\/option><option value=\"Cabo Verde\"  data-calculation=\"0\">Cabo Verde<\/option><option value=\"Cambodia\"  data-calculation=\"0\">Cambodia<\/option><option value=\"Cameroon\"  data-calculation=\"0\">Cameroon<\/option><option value=\"Canada\"  data-calculation=\"0\">Canada<\/option><option value=\"Cayman Islands\"  data-calculation=\"0\">Cayman Islands<\/option><option value=\"Central African Republic\"  data-calculation=\"0\">Central African Republic<\/option><option value=\"Chad\"  data-calculation=\"0\">Chad<\/option><option value=\"Chile\"  data-calculation=\"0\">Chile<\/option><option value=\"China\"  data-calculation=\"0\">China<\/option><option value=\"Christmas Island\"  data-calculation=\"0\">Christmas Island<\/option><option value=\"Cocos Islands\"  data-calculation=\"0\">Cocos Islands<\/option><option value=\"Colombia\"  data-calculation=\"0\">Colombia<\/option><option value=\"Comoros\"  data-calculation=\"0\">Comoros<\/option><option value=\"Congo, Democratic Republic of the\"  data-calculation=\"0\">Congo, Democratic Republic of the<\/option><option value=\"Congo, Republic of the\"  data-calculation=\"0\">Congo, Republic of the<\/option><option value=\"Cook Islands\"  data-calculation=\"0\">Cook Islands<\/option><option value=\"Costa Rica\"  data-calculation=\"0\">Costa Rica<\/option><option value=\"C\u00f4te d&#039;Ivoire\"  data-calculation=\"0\">C\u00f4te d&#8217;Ivoire<\/option><option value=\"Croatia\"  data-calculation=\"0\">Croatia<\/option><option value=\"Cuba\"  data-calculation=\"0\">Cuba<\/option><option value=\"Cura\u00e7ao\"  data-calculation=\"0\">Cura\u00e7ao<\/option><option value=\"Cyprus\"  data-calculation=\"0\">Cyprus<\/option><option value=\"Czech Republic\"  data-calculation=\"0\">Czech Republic<\/option><option value=\"Denmark\"  data-calculation=\"0\">Denmark<\/option><option value=\"Djibouti\"  data-calculation=\"0\">Djibouti<\/option><option value=\"Dominica\"  data-calculation=\"0\">Dominica<\/option><option value=\"Dominican Republic\"  data-calculation=\"0\">Dominican Republic<\/option><option value=\"Ecuador\"  data-calculation=\"0\">Ecuador<\/option><option value=\"Egypt\"  data-calculation=\"0\">Egypt<\/option><option value=\"El Salvador\"  data-calculation=\"0\">El Salvador<\/option><option value=\"Equatorial Guinea\"  data-calculation=\"0\">Equatorial Guinea<\/option><option value=\"Eritrea\"  data-calculation=\"0\">Eritrea<\/option><option value=\"Estonia\"  data-calculation=\"0\">Estonia<\/option><option value=\"Eswatini\"  data-calculation=\"0\">Eswatini<\/option><option value=\"Ethiopia\"  data-calculation=\"0\">Ethiopia<\/option><option value=\"Falkland Islands\"  data-calculation=\"0\">Falkland Islands<\/option><option value=\"Faroe Islands\"  data-calculation=\"0\">Faroe Islands<\/option><option value=\"Fiji\"  data-calculation=\"0\">Fiji<\/option><option value=\"Finland\"  data-calculation=\"0\">Finland<\/option><option value=\"France\"  data-calculation=\"0\">France<\/option><option value=\"French Guiana\"  data-calculation=\"0\">French Guiana<\/option><option value=\"French Polynesia\"  data-calculation=\"0\">French Polynesia<\/option><option value=\"French Southern Territories\"  data-calculation=\"0\">French Southern Territories<\/option><option value=\"Gabon\"  data-calculation=\"0\">Gabon<\/option><option value=\"Gambia\"  data-calculation=\"0\">Gambia<\/option><option value=\"Georgia\"  data-calculation=\"0\">Georgia<\/option><option value=\"Germany\"  data-calculation=\"0\">Germany<\/option><option value=\"Ghana\"  data-calculation=\"0\">Ghana<\/option><option value=\"Gibraltar\"  data-calculation=\"0\">Gibraltar<\/option><option value=\"Greece\"  data-calculation=\"0\">Greece<\/option><option value=\"Greenland\"  data-calculation=\"0\">Greenland<\/option><option value=\"Grenada\"  data-calculation=\"0\">Grenada<\/option><option value=\"Guadeloupe\"  data-calculation=\"0\">Guadeloupe<\/option><option value=\"Guam\"  data-calculation=\"0\">Guam<\/option><option value=\"Guatemala\"  data-calculation=\"0\">Guatemala<\/option><option value=\"Guernsey\"  data-calculation=\"0\">Guernsey<\/option><option value=\"Guinea\"  data-calculation=\"0\">Guinea<\/option><option value=\"Guinea-Bissau\"  data-calculation=\"0\">Guinea-Bissau<\/option><option value=\"Guyana\"  data-calculation=\"0\">Guyana<\/option><option value=\"Haiti\"  data-calculation=\"0\">Haiti<\/option><option value=\"Heard and McDonald Islands\"  data-calculation=\"0\">Heard and McDonald Islands<\/option><option value=\"Holy See\"  data-calculation=\"0\">Holy See<\/option><option value=\"Honduras\"  data-calculation=\"0\">Honduras<\/option><option value=\"Hong Kong\"  data-calculation=\"0\">Hong Kong<\/option><option value=\"Hungary\"  data-calculation=\"0\">Hungary<\/option><option value=\"Iceland\"  data-calculation=\"0\">Iceland<\/option><option value=\"India\"  data-calculation=\"0\">India<\/option><option value=\"Indonesia\"  data-calculation=\"0\">Indonesia<\/option><option value=\"Iran\"  data-calculation=\"0\">Iran<\/option><option value=\"Iraq\"  data-calculation=\"0\">Iraq<\/option><option value=\"Ireland\"  data-calculation=\"0\">Ireland<\/option><option value=\"Isle of Man\"  data-calculation=\"0\">Isle of Man<\/option><option value=\"Italy\"  data-calculation=\"0\">Italy<\/option><option value=\"Jamaica\"  data-calculation=\"0\">Jamaica<\/option><option value=\"Japan\"  data-calculation=\"0\">Japan<\/option><option value=\"Jersey\"  data-calculation=\"0\">Jersey<\/option><option value=\"Jordan\"  data-calculation=\"0\">Jordan<\/option><option value=\"Kazakhstan\"  data-calculation=\"0\">Kazakhstan<\/option><option value=\"Kenya\"  data-calculation=\"0\">Kenya<\/option><option value=\"Kiribati\"  data-calculation=\"0\">Kiribati<\/option><option value=\"Kuwait\"  data-calculation=\"0\">Kuwait<\/option><option value=\"Kyrgyzstan\"  data-calculation=\"0\">Kyrgyzstan<\/option><option value=\"Lao People&#039;s Democratic Republic\"  data-calculation=\"0\">Lao People&#8217;s Democratic Republic<\/option><option value=\"Latvia\"  data-calculation=\"0\">Latvia<\/option><option value=\"Lebanon\"  data-calculation=\"0\">Lebanon<\/option><option value=\"Lesotho\"  data-calculation=\"0\">Lesotho<\/option><option value=\"Liberia\"  data-calculation=\"0\">Liberia<\/option><option value=\"Libya\"  data-calculation=\"0\">Libya<\/option><option value=\"Liechtenstein\"  data-calculation=\"0\">Liechtenstein<\/option><option value=\"Lithuania\"  data-calculation=\"0\">Lithuania<\/option><option value=\"Luxembourg\"  data-calculation=\"0\">Luxembourg<\/option><option value=\"Macau\"  data-calculation=\"0\">Macau<\/option><option value=\"Madagascar\"  data-calculation=\"0\">Madagascar<\/option><option value=\"Malawi\"  data-calculation=\"0\">Malawi<\/option><option value=\"Malaysia\"  data-calculation=\"0\">Malaysia<\/option><option value=\"Maldives\"  data-calculation=\"0\">Maldives<\/option><option value=\"Mali\"  data-calculation=\"0\">Mali<\/option><option value=\"Malta\"  data-calculation=\"0\">Malta<\/option><option value=\"Marshall Islands\"  data-calculation=\"0\">Marshall Islands<\/option><option value=\"Martinique\"  data-calculation=\"0\">Martinique<\/option><option value=\"Mauritania\"  data-calculation=\"0\">Mauritania<\/option><option value=\"Mauritius\"  data-calculation=\"0\">Mauritius<\/option><option value=\"Mayotte\"  data-calculation=\"0\">Mayotte<\/option><option value=\"Mexico\"  data-calculation=\"0\">Mexico<\/option><option value=\"Micronesia\"  data-calculation=\"0\">Micronesia<\/option><option value=\"Moldova\"  data-calculation=\"0\">Moldova<\/option><option value=\"Monaco\"  data-calculation=\"0\">Monaco<\/option><option value=\"Mongolia\"  data-calculation=\"0\">Mongolia<\/option><option value=\"Montenegro\"  data-calculation=\"0\">Montenegro<\/option><option value=\"Montserrat\"  data-calculation=\"0\">Montserrat<\/option><option value=\"Morocco\"  data-calculation=\"0\">Morocco<\/option><option value=\"Mozambique\"  data-calculation=\"0\">Mozambique<\/option><option value=\"Myanmar\"  data-calculation=\"0\">Myanmar<\/option><option value=\"Namibia\"  data-calculation=\"0\">Namibia<\/option><option value=\"Nauru\"  data-calculation=\"0\">Nauru<\/option><option value=\"Nepal\"  data-calculation=\"0\">Nepal<\/option><option value=\"Netherlands\"  data-calculation=\"0\">Netherlands<\/option><option value=\"New Caledonia\"  data-calculation=\"0\">New Caledonia<\/option><option value=\"New Zealand\"  data-calculation=\"0\">New Zealand<\/option><option value=\"Nicaragua\"  data-calculation=\"0\">Nicaragua<\/option><option value=\"Niger\"  data-calculation=\"0\">Niger<\/option><option value=\"Nigeria\"  data-calculation=\"0\">Nigeria<\/option><option value=\"Niue\"  data-calculation=\"0\">Niue<\/option><option value=\"Norfolk Island\"  data-calculation=\"0\">Norfolk Island<\/option><option value=\"North Korea\"  data-calculation=\"0\">North Korea<\/option><option value=\"North Macedonia\"  data-calculation=\"0\">North Macedonia<\/option><option value=\"Northern Mariana Islands\"  data-calculation=\"0\">Northern Mariana Islands<\/option><option value=\"Norway\"  data-calculation=\"0\">Norway<\/option><option value=\"Oman\"  data-calculation=\"0\">Oman<\/option><option value=\"Pakistan\"  data-calculation=\"0\">Pakistan<\/option><option value=\"Palau\"  data-calculation=\"0\">Palau<\/option><option value=\"Palestine, State of\"  data-calculation=\"0\">Palestine, State of<\/option><option value=\"Panama\"  data-calculation=\"0\">Panama<\/option><option value=\"Papua New Guinea\"  data-calculation=\"0\">Papua New Guinea<\/option><option value=\"Paraguay\"  data-calculation=\"0\">Paraguay<\/option><option value=\"Peru\"  data-calculation=\"0\">Peru<\/option><option value=\"Philippines\"  data-calculation=\"0\">Philippines<\/option><option value=\"Pitcairn\"  data-calculation=\"0\">Pitcairn<\/option><option value=\"Poland\"  data-calculation=\"0\">Poland<\/option><option value=\"Portugal\"  data-calculation=\"0\">Portugal<\/option><option value=\"Puerto Rico\"  data-calculation=\"0\">Puerto Rico<\/option><option value=\"Qatar\"  data-calculation=\"0\">Qatar<\/option><option value=\"R\u00e9union\"  data-calculation=\"0\">R\u00e9union<\/option><option value=\"Romania\"  data-calculation=\"0\">Romania<\/option><option value=\"Russia\"  data-calculation=\"0\">Russia<\/option><option value=\"Rwanda\"  data-calculation=\"0\">Rwanda<\/option><option value=\"Saint Barth\u00e9lemy\"  data-calculation=\"0\">Saint Barth\u00e9lemy<\/option><option value=\"Saint Helena, Ascension and Tristan da Cunha\"  data-calculation=\"0\">Saint Helena, Ascension and Tristan da Cunha<\/option><option value=\"Saint Kitts and Nevis\"  data-calculation=\"0\">Saint Kitts and Nevis<\/option><option value=\"Saint Lucia\"  data-calculation=\"0\">Saint Lucia<\/option><option value=\"Saint Martin\"  data-calculation=\"0\">Saint Martin<\/option><option value=\"Saint Pierre and Miquelon\"  data-calculation=\"0\">Saint Pierre and Miquelon<\/option><option value=\"Saint Vincent and the Grenadines\"  data-calculation=\"0\">Saint Vincent and the Grenadines<\/option><option value=\"Samoa\"  data-calculation=\"0\">Samoa<\/option><option value=\"San Marino\"  data-calculation=\"0\">San Marino<\/option><option value=\"Sao Tome and Principe\"  data-calculation=\"0\">Sao Tome and Principe<\/option><option value=\"Saudi Arabia\" selected=\"selected\" data-calculation=\"0\">Saudi Arabia<\/option><option value=\"Senegal\"  data-calculation=\"0\">Senegal<\/option><option value=\"Serbia\"  data-calculation=\"0\">Serbia<\/option><option value=\"Seychelles\"  data-calculation=\"0\">Seychelles<\/option><option value=\"Sierra Leone\"  data-calculation=\"0\">Sierra Leone<\/option><option value=\"Singapore\"  data-calculation=\"0\">Singapore<\/option><option value=\"Sint Maarten\"  data-calculation=\"0\">Sint Maarten<\/option><option value=\"Slovakia\"  data-calculation=\"0\">Slovakia<\/option><option value=\"Slovenia\"  data-calculation=\"0\">Slovenia<\/option><option value=\"Solomon Islands\"  data-calculation=\"0\">Solomon Islands<\/option><option value=\"Somalia\"  data-calculation=\"0\">Somalia<\/option><option value=\"South Africa\"  data-calculation=\"0\">South Africa<\/option><option value=\"South Georgia and the South Sandwich Islands\"  data-calculation=\"0\">South Georgia and the South Sandwich Islands<\/option><option value=\"South Korea\"  data-calculation=\"0\">South Korea<\/option><option value=\"South Sudan\"  data-calculation=\"0\">South Sudan<\/option><option value=\"Spain\"  data-calculation=\"0\">Spain<\/option><option value=\"Sri Lanka\"  data-calculation=\"0\">Sri Lanka<\/option><option value=\"Sudan\"  data-calculation=\"0\">Sudan<\/option><option value=\"Suriname\"  data-calculation=\"0\">Suriname<\/option><option value=\"Svalbard and Jan Mayen Islands\"  data-calculation=\"0\">Svalbard and Jan Mayen Islands<\/option><option value=\"Sweden\"  data-calculation=\"0\">Sweden<\/option><option value=\"Switzerland\"  data-calculation=\"0\">Switzerland<\/option><option value=\"Syria\"  data-calculation=\"0\">Syria<\/option><option value=\"Taiwan\"  data-calculation=\"0\">Taiwan<\/option><option value=\"Tajikistan\"  data-calculation=\"0\">Tajikistan<\/option><option value=\"Tanzania\"  data-calculation=\"0\">Tanzania<\/option><option value=\"Thailand\"  data-calculation=\"0\">Thailand<\/option><option value=\"Timor-Leste\"  data-calculation=\"0\">Timor-Leste<\/option><option value=\"Togo\"  data-calculation=\"0\">Togo<\/option><option value=\"Tokelau\"  data-calculation=\"0\">Tokelau<\/option><option value=\"Tonga\"  data-calculation=\"0\">Tonga<\/option><option value=\"Trinidad and Tobago\"  data-calculation=\"0\">Trinidad and Tobago<\/option><option value=\"Tunisia\"  data-calculation=\"0\">Tunisia<\/option><option value=\"Turkey\"  data-calculation=\"0\">Turkey<\/option><option value=\"Turkmenistan\"  data-calculation=\"0\">Turkmenistan<\/option><option value=\"Turks and Caicos Islands\"  data-calculation=\"0\">Turks and Caicos Islands<\/option><option value=\"Tuvalu\"  data-calculation=\"0\">Tuvalu<\/option><option value=\"Uganda\"  data-calculation=\"0\">Uganda<\/option><option value=\"Ukraine\"  data-calculation=\"0\">Ukraine<\/option><option value=\"United Arab Emirates\"  data-calculation=\"0\">United Arab Emirates<\/option><option value=\"United Kingdom\"  data-calculation=\"0\">United Kingdom<\/option><option value=\"United States\"  data-calculation=\"0\">United States<\/option><option value=\"Uruguay\"  data-calculation=\"0\">Uruguay<\/option><option value=\"US Minor Outlying Islands\"  data-calculation=\"0\">US Minor Outlying Islands<\/option><option value=\"Uzbekistan\"  data-calculation=\"0\">Uzbekistan<\/option><option value=\"Vanuatu\"  data-calculation=\"0\">Vanuatu<\/option><option value=\"Venezuela\"  data-calculation=\"0\">Venezuela<\/option><option value=\"Vietnam\"  data-calculation=\"0\">Vietnam<\/option><option value=\"Virgin Islands, British\"  data-calculation=\"0\">Virgin Islands, British<\/option><option value=\"Virgin Islands, U.S.\"  data-calculation=\"0\">Virgin Islands, U.S.<\/option><option value=\"Wallis and Futuna\"  data-calculation=\"0\">Wallis and Futuna<\/option><option value=\"Western Sahara\"  data-calculation=\"0\">Western Sahara<\/option><option value=\"Yemen\"  data-calculation=\"0\">Yemen<\/option><option value=\"Zambia\"  data-calculation=\"0\">Zambia<\/option><option value=\"Zimbabwe\"  data-calculation=\"0\">Zimbabwe<\/option><option value=\"Other\"  data-calculation=\"0\">Other<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-1\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-1_6a2782b49278b\" id=\"forminator-field-text-1_6a2782b49278b-label\" class=\"forminator-label\">ID\/IQAMA\/ Passport<\/label><span id=\"forminator-field-text-1_6a2782b49278b-description\" class=\"forminator-description\">Enter<\/span><input type=\"text\" name=\"text-1\" value=\"\" placeholder=\"E.g. 1234567890\" id=\"forminator-field-text-1_6a2782b49278b\" class=\"forminator-input forminator-name--field\" data-required=\"\" aria-describedby=\"forminator-field-text-1_6a2782b49278b-description\" \/><\/div><\/div><div id=\"text-2\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-2_6a2782b49278b\" id=\"forminator-field-text-2_6a2782b49278b-label\" class=\"forminator-label\">Is the case related to an event, worksite, or specific location?<\/label><span id=\"forminator-field-text-2_6a2782b49278b-description\" class=\"forminator-description\">If yes, please specify the name of the company.<\/span><input type=\"text\" name=\"text-2\" value=\"\" placeholder=\"\" id=\"forminator-field-text-2_6a2782b49278b\" class=\"forminator-input forminator-name--field\" data-required=\"\" aria-describedby=\"forminator-field-text-2_6a2782b49278b-description\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-1\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-1-6a2782b49278b-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-1-6a2782b49278b-label\" class=\"forminator-label\">Select Chief Complaint<\/span><span id=\"forminator-field-checkbox-1-6a2782b49278b-description\" class=\"forminator-description\">Chief Complaint<\/span><label id=\"forminator-field-checkbox-1-1-6a2782b49278b-label\" for=\"forminator-field-checkbox-1-1-6a2782b49278b\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Abdominal Pain\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Abdominal Pain\" id=\"forminator-field-checkbox-1-1-6a2782b49278b\" aria-labelledby=\"forminator-field-checkbox-1-1-6a2782b49278b-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-1-6a2782b49278b-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Abdominal Pain<\/span><\/label><label id=\"forminator-field-checkbox-1-2-6a2782b49278b-label\" for=\"forminator-field-checkbox-1-2-6a2782b49278b\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Allergic Reaction\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Allergic Reaction\" id=\"forminator-field-checkbox-1-2-6a2782b49278b\" aria-labelledby=\"forminator-field-checkbox-1-2-6a2782b49278b-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-1-6a2782b49278b-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Allergic Reaction<\/span><\/label><label id=\"forminator-field-checkbox-1-3-6a2782b49278b-label\" for=\"forminator-field-checkbox-1-3-6a2782b49278b\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Back Pain\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Back Pain\" id=\"forminator-field-checkbox-1-3-6a2782b49278b\" aria-labelledby=\"forminator-field-checkbox-1-3-6a2782b49278b-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-1-6a2782b49278b-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Back Pain<\/span><\/label><label id=\"forminator-field-checkbox-1-4-6a2782b49278b-label\" for=\"forminator-field-checkbox-1-4-6a2782b49278b\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Behavioral Emergency\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Behavioral Emergency\" id=\"forminator-field-checkbox-1-4-6a2782b49278b\" aria-labelledby=\"forminator-field-checkbox-1-4-6a2782b49278b-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-1-6a2782b49278b-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Behavioral Emergency<\/span><\/label><label id=\"forminator-field-checkbox-1-5-6a2782b49278b-label\" for=\"forminator-field-checkbox-1-5-6a2782b49278b\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Blunt Force Trauma\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Blunt Force Trauma\" id=\"forminator-field-checkbox-1-5-6a2782b49278b\" aria-labelledby=\"forminator-field-checkbox-1-5-6a2782b49278b-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-1-6a2782b49278b-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Blunt Force Trauma<\/span><\/label><label id=\"forminator-field-checkbox-1-6-6a2782b49278b-label\" for=\"forminator-field-checkbox-1-6-6a2782b49278b\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Burns\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Burns\" id=\"forminator-field-checkbox-1-6-6a2782b49278b\" aria-labelledby=\"forminator-field-checkbox-1-6-6a2782b49278b-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-1-6a2782b49278b-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Burns<\/span><\/label><label id=\"forminator-field-checkbox-1-7-6a2782b49278b-label\" for=\"forminator-field-checkbox-1-7-6a2782b49278b\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Cardiac Arrest\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Cardiac Arrest\" id=\"forminator-field-checkbox-1-7-6a2782b49278b\" aria-labelledby=\"forminator-field-checkbox-1-7-6a2782b49278b-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-1-6a2782b49278b-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Cardiac Arrest<\/span><\/label><label id=\"forminator-field-checkbox-1-8-6a2782b49278b-label\" for=\"forminator-field-checkbox-1-8-6a2782b49278b\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Chest Pain\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Chest Pain\" id=\"forminator-field-checkbox-1-8-6a2782b49278b\" aria-labelledby=\"forminator-field-checkbox-1-8-6a2782b49278b-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-1-6a2782b49278b-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Chest Pain<\/span><\/label><label id=\"forminator-field-checkbox-1-9-6a2782b49278b-label\" for=\"forminator-field-checkbox-1-9-6a2782b49278b\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Cold-Related Illness\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Cold-Related Illness\" id=\"forminator-field-checkbox-1-9-6a2782b49278b\" aria-labelledby=\"forminator-field-checkbox-1-9-6a2782b49278b-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-1-6a2782b49278b-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Cold-Related Illness<\/span><\/label><label id=\"forminator-field-checkbox-1-10-6a2782b49278b-label\" for=\"forminator-field-checkbox-1-10-6a2782b49278b\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Diabetic Emergency\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Diabetic Emergency\" id=\"forminator-field-checkbox-1-10-6a2782b49278b\" aria-labelledby=\"forminator-field-checkbox-1-10-6a2782b49278b-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-1-6a2782b49278b-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Diabetic Emergency<\/span><\/label><label id=\"forminator-field-checkbox-1-11-6a2782b49278b-label\" for=\"forminator-field-checkbox-1-11-6a2782b49278b\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Difficulty Breathing\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Difficulty Breathing\" id=\"forminator-field-checkbox-1-11-6a2782b49278b\" aria-labelledby=\"forminator-field-checkbox-1-11-6a2782b49278b-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-1-6a2782b49278b-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Difficulty Breathing<\/span><\/label><label id=\"forminator-field-checkbox-1-12-6a2782b49278b-label\" for=\"forminator-field-checkbox-1-12-6a2782b49278b\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Dizziness\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Dizziness\" id=\"forminator-field-checkbox-1-12-6a2782b49278b\" aria-labelledby=\"forminator-field-checkbox-1-12-6a2782b49278b-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-1-6a2782b49278b-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Dizziness<\/span><\/label><label id=\"forminator-field-checkbox-1-13-6a2782b49278b-label\" for=\"forminator-field-checkbox-1-13-6a2782b49278b\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"External Bleeding\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"External Bleeding\" id=\"forminator-field-checkbox-1-13-6a2782b49278b\" aria-labelledby=\"forminator-field-checkbox-1-13-6a2782b49278b-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-1-6a2782b49278b-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">External Bleeding<\/span><\/label><label id=\"forminator-field-checkbox-1-14-6a2782b49278b-label\" for=\"forminator-field-checkbox-1-14-6a2782b49278b\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Fainting \/ Syncope\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Fainting \/ Syncope\" id=\"forminator-field-checkbox-1-14-6a2782b49278b\" aria-labelledby=\"forminator-field-checkbox-1-14-6a2782b49278b-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-1-6a2782b49278b-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Fainting \/ Syncope<\/span><\/label><label id=\"forminator-field-checkbox-1-15-6a2782b49278b-label\" for=\"forminator-field-checkbox-1-15-6a2782b49278b\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Fever\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Fever\" id=\"forminator-field-checkbox-1-15-6a2782b49278b\" aria-labelledby=\"forminator-field-checkbox-1-15-6a2782b49278b-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-1-6a2782b49278b-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Fever<\/span><\/label><label id=\"forminator-field-checkbox-1-16-6a2782b49278b-label\" for=\"forminator-field-checkbox-1-16-6a2782b49278b\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Head Injury\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Head Injury\" id=\"forminator-field-checkbox-1-16-6a2782b49278b\" aria-labelledby=\"forminator-field-checkbox-1-16-6a2782b49278b-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-1-6a2782b49278b-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Head Injury<\/span><\/label><label id=\"forminator-field-checkbox-1-17-6a2782b49278b-label\" for=\"forminator-field-checkbox-1-17-6a2782b49278b\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Headache\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Headache\" id=\"forminator-field-checkbox-1-17-6a2782b49278b\" aria-labelledby=\"forminator-field-checkbox-1-17-6a2782b49278b-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-1-6a2782b49278b-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Headache<\/span><\/label><label id=\"forminator-field-checkbox-1-18-6a2782b49278b-label\" for=\"forminator-field-checkbox-1-18-6a2782b49278b\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Heat-Related Illness\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Heat-Related Illness\" id=\"forminator-field-checkbox-1-18-6a2782b49278b\" aria-labelledby=\"forminator-field-checkbox-1-18-6a2782b49278b-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-1-6a2782b49278b-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Heat-Related Illness<\/span><\/label><label id=\"forminator-field-checkbox-1-19-6a2782b49278b-label\" for=\"forminator-field-checkbox-1-19-6a2782b49278b\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Injury from Fall\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Injury from Fall\" id=\"forminator-field-checkbox-1-19-6a2782b49278b\" aria-labelledby=\"forminator-field-checkbox-1-19-6a2782b49278b-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-1-6a2782b49278b-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Injury from Fall<\/span><\/label><label id=\"forminator-field-checkbox-1-20-6a2782b49278b-label\" for=\"forminator-field-checkbox-1-20-6a2782b49278b\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Loss of Consciousness\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Loss of Consciousness\" id=\"forminator-field-checkbox-1-20-6a2782b49278b\" aria-labelledby=\"forminator-field-checkbox-1-20-6a2782b49278b-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-1-6a2782b49278b-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Loss of Consciousness<\/span><\/label><label id=\"forminator-field-checkbox-1-21-6a2782b49278b-label\" for=\"forminator-field-checkbox-1-21-6a2782b49278b\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Motor Vehicle Collision\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Motor Vehicle Collision\" id=\"forminator-field-checkbox-1-21-6a2782b49278b\" aria-labelledby=\"forminator-field-checkbox-1-21-6a2782b49278b-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-1-6a2782b49278b-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Motor Vehicle Collision<\/span><\/label><label id=\"forminator-field-checkbox-1-22-6a2782b49278b-label\" for=\"forminator-field-checkbox-1-22-6a2782b49278b\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Nausea \/ Vomiting\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Nausea \/ Vomiting\" id=\"forminator-field-checkbox-1-22-6a2782b49278b\" aria-labelledby=\"forminator-field-checkbox-1-22-6a2782b49278b-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-1-6a2782b49278b-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Nausea \/ Vomiting<\/span><\/label><label id=\"forminator-field-checkbox-1-23-6a2782b49278b-label\" for=\"forminator-field-checkbox-1-23-6a2782b49278b\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Overdose \/ Poisoning\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Overdose \/ Poisoning\" id=\"forminator-field-checkbox-1-23-6a2782b49278b\" aria-labelledby=\"forminator-field-checkbox-1-23-6a2782b49278b-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-1-6a2782b49278b-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Overdose \/ Poisoning<\/span><\/label><label id=\"forminator-field-checkbox-1-24-6a2782b49278b-label\" for=\"forminator-field-checkbox-1-24-6a2782b49278b\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Palpitations\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Palpitations\" id=\"forminator-field-checkbox-1-24-6a2782b49278b\" aria-labelledby=\"forminator-field-checkbox-1-24-6a2782b49278b-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-1-6a2782b49278b-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Palpitations<\/span><\/label><label id=\"forminator-field-checkbox-1-25-6a2782b49278b-label\" for=\"forminator-field-checkbox-1-25-6a2782b49278b\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Penetrating Injury\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Penetrating Injury\" id=\"forminator-field-checkbox-1-25-6a2782b49278b\" aria-labelledby=\"forminator-field-checkbox-1-25-6a2782b49278b-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-1-6a2782b49278b-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Penetrating Injury<\/span><\/label><label id=\"forminator-field-checkbox-1-26-6a2782b49278b-label\" for=\"forminator-field-checkbox-1-26-6a2782b49278b\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Pregnancy-Related Issue\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Pregnancy-Related Issue\" id=\"forminator-field-checkbox-1-26-6a2782b49278b\" aria-labelledby=\"forminator-field-checkbox-1-26-6a2782b49278b-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-1-6a2782b49278b-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Pregnancy-Related Issue<\/span><\/label><label id=\"forminator-field-checkbox-1-27-6a2782b49278b-label\" for=\"forminator-field-checkbox-1-27-6a2782b49278b\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Respiratory Distress\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Respiratory Distress\" id=\"forminator-field-checkbox-1-27-6a2782b49278b\" aria-labelledby=\"forminator-field-checkbox-1-27-6a2782b49278b-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-1-6a2782b49278b-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Respiratory Distress<\/span><\/label><label id=\"forminator-field-checkbox-1-28-6a2782b49278b-label\" for=\"forminator-field-checkbox-1-28-6a2782b49278b\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Seizure\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Seizure\" id=\"forminator-field-checkbox-1-28-6a2782b49278b\" aria-labelledby=\"forminator-field-checkbox-1-28-6a2782b49278b-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-1-6a2782b49278b-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Seizure<\/span><\/label><label id=\"forminator-field-checkbox-1-29-6a2782b49278b-label\" for=\"forminator-field-checkbox-1-29-6a2782b49278b\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Shortness of Breath\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Shortness of Breath\" id=\"forminator-field-checkbox-1-29-6a2782b49278b\" aria-labelledby=\"forminator-field-checkbox-1-29-6a2782b49278b-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-1-6a2782b49278b-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Shortness of Breath<\/span><\/label><label id=\"forminator-field-checkbox-1-30-6a2782b49278b-label\" for=\"forminator-field-checkbox-1-30-6a2782b49278b\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Stroke Symptoms\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Stroke Symptoms\" id=\"forminator-field-checkbox-1-30-6a2782b49278b\" aria-labelledby=\"forminator-field-checkbox-1-30-6a2782b49278b-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-1-6a2782b49278b-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Stroke Symptoms<\/span><\/label><label id=\"forminator-field-checkbox-1-31-6a2782b49278b-label\" for=\"forminator-field-checkbox-1-31-6a2782b49278b\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Superficial Wound\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Superficial Wound\" id=\"forminator-field-checkbox-1-31-6a2782b49278b\" aria-labelledby=\"forminator-field-checkbox-1-31-6a2782b49278b-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-1-6a2782b49278b-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Superficial Wound<\/span><\/label><label id=\"forminator-field-checkbox-1-32-6a2782b49278b-label\" for=\"forminator-field-checkbox-1-32-6a2782b49278b\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Trauma (Unspecified)\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Trauma (Unspecified)\" id=\"forminator-field-checkbox-1-32-6a2782b49278b\" aria-labelledby=\"forminator-field-checkbox-1-32-6a2782b49278b-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-1-6a2782b49278b-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Trauma (Unspecified)<\/span><\/label><label id=\"forminator-field-checkbox-1-33-6a2782b49278b-label\" for=\"forminator-field-checkbox-1-33-6a2782b49278b\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Weakness\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Weakness\" id=\"forminator-field-checkbox-1-33-6a2782b49278b\" aria-labelledby=\"forminator-field-checkbox-1-33-6a2782b49278b-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-1-6a2782b49278b-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Weakness<\/span><\/label><label id=\"forminator-field-checkbox-1-34-6a2782b49278b-label\" for=\"forminator-field-checkbox-1-34-6a2782b49278b\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Other (specify)\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Other (specify)\" id=\"forminator-field-checkbox-1-34-6a2782b49278b\" aria-labelledby=\"forminator-field-checkbox-1-34-6a2782b49278b-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-1-6a2782b49278b-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Other (specify)<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-1\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-1_6a2782b49278b\" id=\"forminator-field-textarea-1_6a2782b49278b-label\" class=\"forminator-label\">History of Present Illness \/ MEDICAL NOTE \/ \u062a\u0641\u0627\u0635\u064a\u0644 \u0627\u0644\u062d\u0627\u0644\u0629 \u0627\u0644\u0645\u0631\u0636\u064a\u0629<\/label><textarea name=\"textarea-1\" placeholder=\"For example: Upon arrival on the scene we found one male pt 55 Y.O. GCS15 sitting on his bed, complaining of chest pain and palpitation associated with nausea and Vomiting. The chest pain started 2 Hrs ago, radiating to the Lt shoulder and upper back, The pain score 6\/10. The pt W\/ Hx of HTN, DM, IHD and Migraine. \nNo loss of consciousness, No Dizziness, No SOB, No Diarrhea or constipation \nWith no other associated signs or symptoms were noted or reported.\" id=\"forminator-field-textarea-1_6a2782b49278b\" class=\"forminator-textarea\" style=\"--forminator-textarea-min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"group-1\" class=\"forminator-field-group forminator-col forminator-col-12 \"><label class=\"forminator-label forminator-repeater-label\">Vital Signs<\/label><div class=\"forminator-all-group-copies forminator-repeater-field\"><div class=\"forminator-grouped-fields\" data-options=\"{&quot;is_repeater&quot;:true,&quot;min_type&quot;:&quot;custom&quot;,&quot;max_type&quot;:&quot;custom&quot;,&quot;min&quot;:1,&quot;max&quot;:9223372036854775807,&quot;add_text&quot;:&quot;Add item&quot;,&quot;remove_text&quot;:&quot;Remove item&quot;,&quot;action_element_type&quot;:&quot;button&quot;}\"><div class=\"forminator-row\"><div id=\"select-6\" class=\"forminator-field-select forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-610__field--select-6_6a2782b49278b\" id=\"forminator-form-610__field--select-6_6a2782b49278b-label\" class=\"forminator-label\">Eye Response (E)<\/label><select  id=\"forminator-form-610__field--select-6_6a2782b49278b\" class=\"forminator-select--field forminator-select2 forminator-select2-multiple\" data-required=\"\" name=\"select-6\" data-default-value=\"\" data-hidden-behavior=\"zero\" data-placeholder=\"\" data-search=\"false\" data-search-placeholder=\"\" data-checkbox=\"false\" data-allow-clear=\"false\" aria-labelledby=\"forminator-form-610__field--select-6_6a2782b49278b-label\"><option value=\"4\"  data-calculation=\"4\">Eyes &#8211; Spontaneous<\/option><option value=\"3\"  data-calculation=\"3\">Eyes &#8211; To Speech<\/option><option value=\"2\"  data-calculation=\"2\">Eyes &#8211; To Pain<\/option><option value=\"1\"  data-calculation=\"1\">Eyes &#8211; No Response<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-7\" class=\"forminator-field-select forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-610__field--select-7_6a2782b49278b\" id=\"forminator-form-610__field--select-7_6a2782b49278b-label\" class=\"forminator-label\">Verbal Response (V)<\/label><select  id=\"forminator-form-610__field--select-7_6a2782b49278b\" class=\"forminator-select--field forminator-select2 forminator-select2-multiple\" data-required=\"\" name=\"select-7\" data-default-value=\"\" data-hidden-behavior=\"zero\" data-placeholder=\"\" data-search=\"false\" data-search-placeholder=\"\" data-checkbox=\"false\" data-allow-clear=\"false\" aria-labelledby=\"forminator-form-610__field--select-7_6a2782b49278b-label\"><option value=\"5\"  data-calculation=\"5\">Verbal &#8211; Oriented<\/option><option value=\"4\"  data-calculation=\"4\">Verbal &#8211; Confused<\/option><option value=\"3\"  data-calculation=\"3\">Verbal &#8211; Inappropriate Words<\/option><option value=\"2\"  data-calculation=\"2\">Verbal &#8211; Incomprehensible Sounds<\/option><option value=\"1\"  data-calculation=\"1\">Verbal &#8211; No Response<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-8\" class=\"forminator-field-select forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-610__field--select-8_6a2782b49278b\" id=\"forminator-form-610__field--select-8_6a2782b49278b-label\" class=\"forminator-label\">Motor Response (M)<\/label><select  id=\"forminator-form-610__field--select-8_6a2782b49278b\" class=\"forminator-select--field forminator-select2 forminator-select2-multiple\" data-required=\"\" name=\"select-8\" data-default-value=\"\" data-hidden-behavior=\"zero\" data-placeholder=\"\" data-search=\"false\" data-search-placeholder=\"\" data-checkbox=\"false\" data-allow-clear=\"false\" aria-labelledby=\"forminator-form-610__field--select-8_6a2782b49278b-label\"><option value=\"6\"  data-calculation=\"6\">Motor &#8211; Obeys Commands<\/option><option value=\"5\"  data-calculation=\"5\">Motor &#8211; Localizes Pain<\/option><option value=\"4\"  data-calculation=\"4\">Motor &#8211; Withdraws from Pain<\/option><option value=\"3\"  data-calculation=\"3\">Motor &#8211; Abnormal Flexion (Decorticate)<\/option><option value=\"2\"  data-calculation=\"2\">Motor &#8211; Abnormal Extension (Decerebrate)<\/option><option value=\"1\"  data-calculation=\"1\">Motor &#8211; No Response<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"calculation-1\" class=\"forminator-field-calculation forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"calculation-1-field_6a2782b49278b\" id=\"calculation-1-field_6a2782b49278b-label\" class=\"forminator-label\">Calculations<\/label><input type=\"text\" name=\"calculation-1\" value=\"\" id=\"calculation-1-field_6a2782b49278b\" class=\"forminator-calculation forminator-input\" data-formula=\"{select-6}+{select-7}+{select-8}\" data-required=\"\" data-decimal-point=\".\" data-precision=\"2\" data-is-hidden=\"\" disabled=\"disabled\" data-decimals=\"2\" data-inputmask=\"&#039;groupSeparator&#039;: &#039;&#039;, &#039;radixPoint&#039;: &#039;.&#039;, &#039;digits&#039;: &#039;2&#039;\" readonly=\"readonly\" data-hidden-behavior=\"zero\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"number-2\" class=\"forminator-field-number forminator-col forminator-col-3 \"><div class=\"forminator-field\"><label for=\"forminator-field-number-2_6a2782b49278b\" id=\"forminator-field-number-2_6a2782b49278b-label\" class=\"forminator-label\">Temperature<\/label><input name=\"number-2\" value=\"\" placeholder=\"E.g. 37.3\" id=\"forminator-field-number-2_6a2782b49278b\" class=\"forminator-input forminator-number--field\" inputmode=\"decimal\" data-required=\"\" data-decimals=\"0\" aria-required=\"false\" data-inputmask=\"&#039;groupSeparator&#039;: &#039;&#039;, &#039;radixPoint&#039;: &#039;&#039;, &#039;digits&#039;: &#039;0&#039;\" data-hidden-behavior=\"zero\" type=\"number\" step=\"any\" min=\"1\" max=\"150\" \/><\/div><\/div><div id=\"number-3\" class=\"forminator-field-number forminator-col forminator-col-3 \"><div class=\"forminator-field\"><label for=\"forminator-field-number-3_6a2782b49278b\" id=\"forminator-field-number-3_6a2782b49278b-label\" class=\"forminator-label\">Pulse<\/label><input name=\"number-3\" value=\"\" placeholder=\"E.g. 85\" id=\"forminator-field-number-3_6a2782b49278b\" class=\"forminator-input forminator-number--field\" inputmode=\"decimal\" data-required=\"\" data-decimals=\"0\" aria-required=\"false\" data-inputmask=\"&#039;groupSeparator&#039;: &#039;&#039;, &#039;radixPoint&#039;: &#039;&#039;, &#039;digits&#039;: &#039;0&#039;\" data-hidden-behavior=\"zero\" type=\"number\" step=\"any\" min=\"1\" max=\"300\" \/><\/div><\/div><div id=\"number-4\" class=\"forminator-field-number forminator-col forminator-col-3 \"><div class=\"forminator-field\"><label for=\"forminator-field-number-4_6a2782b49278b\" id=\"forminator-field-number-4_6a2782b49278b-label\" class=\"forminator-label\">RR<\/label><input name=\"number-4\" value=\"\" placeholder=\"E.g. 16\" id=\"forminator-field-number-4_6a2782b49278b\" class=\"forminator-input forminator-number--field\" inputmode=\"decimal\" data-required=\"\" data-decimals=\"0\" aria-required=\"false\" data-inputmask=\"&#039;groupSeparator&#039;: &#039;&#039;, &#039;radixPoint&#039;: &#039;&#039;, &#039;digits&#039;: &#039;0&#039;\" data-hidden-behavior=\"zero\" type=\"number\" step=\"any\" min=\"1\" max=\"80\" \/><\/div><\/div><div id=\"number-5\" class=\"forminator-field-number forminator-col forminator-col-3 \"><div class=\"forminator-field\"><label for=\"forminator-field-number-5_6a2782b49278b\" id=\"forminator-field-number-5_6a2782b49278b-label\" class=\"forminator-label\">SpO2<\/label><input name=\"number-5\" value=\"\" placeholder=\"E.g. 99\" id=\"forminator-field-number-5_6a2782b49278b\" class=\"forminator-input forminator-number--field\" inputmode=\"decimal\" data-required=\"\" data-decimals=\"0\" aria-required=\"false\" data-inputmask=\"&#039;groupSeparator&#039;: &#039;&#039;, &#039;radixPoint&#039;: &#039;&#039;, &#039;digits&#039;: &#039;0&#039;\" data-hidden-behavior=\"zero\" type=\"number\" step=\"any\" min=\"1\" max=\"100\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-3\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-3_6a2782b49278b\" id=\"forminator-field-text-3_6a2782b49278b-label\" class=\"forminator-label\">Blood Pressure<\/label><input type=\"text\" name=\"text-3\" value=\"\" placeholder=\"E.g. 120\/80\" id=\"forminator-field-text-3_6a2782b49278b\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"select-5\" class=\"forminator-field-select forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-form-610__field--select-5_6a2782b49278b\" id=\"forminator-form-610__field--select-5_6a2782b49278b-label\" class=\"forminator-label\">Pain Score<\/label><select  id=\"forminator-form-610__field--select-5_6a2782b49278b\" class=\"forminator-select--field forminator-select2 forminator-select2-multiple\" data-required=\"\" name=\"select-5\" data-default-value=\"\" data-hidden-behavior=\"zero\" data-placeholder=\"0-10\" data-search=\"false\" data-search-placeholder=\"0-10\" data-checkbox=\"false\" data-allow-clear=\"false\" aria-labelledby=\"forminator-form-610__field--select-5_6a2782b49278b-label\"><option value=\"\"  >0-10<\/option><option value=\"0\"  data-calculation=\"0\">0<\/option><option value=\"1\"  data-calculation=\"0\">1<\/option><option value=\"2\"  data-calculation=\"0\">2<\/option><option value=\"3\"  data-calculation=\"0\">3<\/option><option value=\"4\"  data-calculation=\"0\">4<\/option><option value=\"5\"  data-calculation=\"0\">5<\/option><option value=\"6\"  data-calculation=\"0\">6<\/option><option value=\"7\"  data-calculation=\"0\">7<\/option><option value=\"8\"  data-calculation=\"0\">8<\/option><option value=\"9\"  data-calculation=\"0\">9<\/option><option value=\"10\"  data-calculation=\"0\">10<\/option><\/select><\/div><\/div><div id=\"number-6\" class=\"forminator-field-number forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-number-6_6a2782b49278b\" id=\"forminator-field-number-6_6a2782b49278b-label\" class=\"forminator-label\">Blood Glucose Level (BGL)<\/label><input name=\"number-6\" value=\"\" placeholder=\"E.g. 120\" id=\"forminator-field-number-6_6a2782b49278b\" class=\"forminator-input forminator-number--field\" inputmode=\"decimal\" data-required=\"\" data-decimals=\"0\" aria-required=\"false\" data-inputmask=\"&#039;groupSeparator&#039;: &#039;&#039;, &#039;radixPoint&#039;: &#039;&#039;, &#039;digits&#039;: &#039;0&#039;\" data-hidden-behavior=\"zero\" type=\"number\" step=\"any\" min=\"1\" max=\"800\" \/><\/div><\/div><\/div><div class=\"forminator-row forminator-action-buttons\"><div class=\"forminator-col forminator-col-12\"><input type=\"button\" value=\"Add item\" class=\"forminator-repeater-action-button forminator-repeater-add\" \/><input type=\"button\" value=\"Remove item\" class=\"forminator-repeater-action-button forminator-repeater-remove\" \/><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-2\" class=\"forminator-field-textarea forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-2_6a2782b49278b\" id=\"forminator-field-textarea-2_6a2782b49278b-label\" class=\"forminator-label\">Management Note<\/label><textarea name=\"textarea-2\" placeholder=\"E.g. We transfer the pt nearest appropriate medical facility \n Administration of 200 CC Normal Saline IV.\nAdministration of Omeprazole 40 Mg IV infusion over 10 Mins\nAdministration of 4 Mg IV Ondansetron.\nAdministration of 2 Mg IV Morphine.\" id=\"forminator-field-textarea-2_6a2782b49278b\" class=\"forminator-textarea\" style=\"--forminator-textarea-min-height:140px;\" ><\/textarea><\/div><\/div><div id=\"textarea-3\" class=\"forminator-field-textarea forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-3_6a2782b49278b\" id=\"forminator-field-textarea-3_6a2782b49278b-label\" class=\"forminator-label\">Transportation Note \/ \u0645\u0644\u0627\u062d\u0638\u0627\u062a \u0646\u0642\u0644 \u0627\u0644\u0645\u0631\u064a\u0636<\/label><textarea name=\"textarea-3\" placeholder=\"\u062a\u0645 \u0646\u0642\u0644 \u0627\u0644\u0645\u0631\u064a\u0636 \u0627\u0644\u0649 \u0627\u0642\u0631\u0628 \u0645\u0646\u0634\u0623\u0629 \u0635\u062d\u064a\u0629 \u0645\u0646\u0627\u0633\u0628\u0629 \u0645\u0633\u062a\u0634\u0641\u0649 \u0627\u0644\u0645\u0644\u0643 \u062e\u0627\u0644\u062f \u0627\u0644\u062c\u0627\u0645\u0639\u064a \/ \u062a\u0645 \u0639\u0644\u0627\u062c \u0627\u0644\u0645\u0631\u064a\u0636 \u0641\u0627\u0644\u0645\u0648\u0642\u0639 \u0648\u0631\u0641\u0636 \u0627\u0644\u0646\u0642\u0644\" id=\"forminator-field-textarea-3_6a2782b49278b\" class=\"forminator-textarea\" style=\"--forminator-textarea-min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-2\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Acceptance\/Refusal Form<\/h2><hr class=\"forminator-border\" style=\"border: 1px solid #333333;\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"group-2\" class=\"forminator-field-group forminator-col forminator-col-12 \"><div class=\"forminator-all-group-copies forminator-repeater-field\"><div class=\"forminator-grouped-fields\" data-options=\"{&quot;is_repeater&quot;:false,&quot;min_type&quot;:&quot;custom&quot;,&quot;max_type&quot;:&quot;custom&quot;,&quot;min&quot;:1,&quot;max&quot;:9223372036854775807,&quot;add_text&quot;:&quot;Add item&quot;,&quot;remove_text&quot;:&quot;Remove item&quot;,&quot;action_element_type&quot;:&quot;button&quot;}\"><div class=\"forminator-row\"><div id=\"radio-2\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-2-6a2782b49278b-label\"><span id=\"forminator-radiogroup-radio-2-6a2782b49278b-label\" class=\"forminator-label\">Does the patient Accept or Refuse Above Report?<\/span><label id=\"forminator-field-radio-2-label-1\" for=\"forminator-field-radio-2-1-6a2782b49278b\" class=\"forminator-radio\" title=\"Accept\"><input type=\"radio\" name=\"radio-2\" value=\"1\" id=\"forminator-field-radio-2-1-6a2782b49278b\" aria-labelledby=\"forminator-field-radio-2-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Accept<\/span><\/label><label id=\"forminator-field-radio-2-label-2\" for=\"forminator-field-radio-2-2-6a2782b49278b\" class=\"forminator-radio\" title=\"Refuse\"><input type=\"radio\" name=\"radio-2\" value=\"0\" id=\"forminator-field-radio-2-2-6a2782b49278b\" aria-labelledby=\"forminator-field-radio-2-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Refuse<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-1\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-1\"><p><strong>Acknowledgment and Informed Consent for Medical Treatment and Transportation<\/strong><\/p>\n<p>I, the undersigned, hereby acknowledge that I have been offered medical assessment, treatment, and\/or transportation to a licensed medical facility by authorized Emergency Medical Services (EMS) personnel. I understand the nature, benefits, and potential risks associated with refusing or delaying medical treatment or transport.<\/p>\n<p>I hereby voluntarily and knowingly consent to receive the medical treatment and transportation provided, in accordance with applicable Saudi Arabian healthcare regulations and professional medical standards. I release and discharge the EMS providers, the attending or consulting physician, and the receiving healthcare facility from any legal liability, except in cases of gross negligence or willful misconduct.<\/p>\n<p><strong>Acknowledgment of Information and Consent<\/strong><\/p>\n<p>I confirm that I have received and understood the above information, and I consent to proceed with the proposed medical care, services, and transportation as deemed necessary.<\/p>\n\n<p style=\"text-align: right;direction: rtl\"><strong>\u0625\u0642\u0631\u0627\u0631 \u0648\u0645\u0648\u0627\u0641\u0642\u0629 \u0639\u0644\u0649 \u0627\u0644\u0639\u0644\u0627\u062c \u0648\u0627\u0644\u0646\u0642\u0644 \u0627\u0644\u0637\u0628\u064a<\/strong><\/p>\n<p style=\"text-align: right;direction: rtl\">\u0623\u0646\u0627 \u0627\u0644\u0645\u0648\u0642\u0639 \u0623\u062f\u0646\u0627\u0647\u060c \u0623\u064f\u0642\u0631\u0651 \u0628\u0623\u0646\u0646\u064a \u0642\u062f \u0639\u064f\u0631\u0636 \u0639\u0644\u064a\u0651 \u062a\u0642\u064a\u064a\u0645 \u0637\u0628\u064a \u0648\u0639\u0644\u0627\u062c \u0648\/\u0623\u0648 \u0646\u0642\u0644 \u0625\u0644\u0649 \u0645\u0646\u0634\u0623\u0629 \u0637\u0628\u064a\u0629 \u0645\u0646\u0627\u0633\u0628\u0629 \u0645\u0646 \u0642\u0628\u0644 \u0645\u0642\u062f\u0645\u064a \u0627\u0644\u062e\u062f\u0645\u0627\u062a \u0627\u0644\u0637\u0628\u064a\u0629 \u0627\u0644\u0637\u0627\u0631\u0626\u0629. \u0648\u0623\u0641\u0647\u0645 \u0637\u0628\u064a\u0639\u0629 \u0648\u0641\u0648\u0627\u0626\u062f \u0648\u0645\u062e\u0627\u0637\u0631 \u0631\u0641\u0636 \u0623\u0648 \u062a\u0623\u062e\u064a\u0631 \u0627\u0644\u0639\u0644\u0627\u062c \u0623\u0648 \u0627\u0644\u0646\u0642\u0644 \u0627\u0644\u0637\u0628\u064a.<\/p>\n<p style=\"text-align: right;direction: rtl\">\u0648\u0623\u0648\u0627\u0641\u0642 \u0628\u0645\u062d\u0636 \u0625\u0631\u0627\u062f\u062a\u064a \u0648\u0628\u0643\u0627\u0645\u0644 \u0648\u0639\u064a\u064a \u0639\u0644\u0649 \u062a\u0644\u0642\u064a \u0627\u0644\u0639\u0644\u0627\u062c \u0627\u0644\u0637\u0628\u064a \u0648\u0627\u0644\u062e\u062f\u0645\u0627\u062a \u0648\u0627\u0644\u0646\u0642\u0644 \u0627\u0644\u0645\u0642\u062f\u0651\u0645 \u0645\u0646 \u0642\u0628\u0644 \u0627\u0644\u0637\u0627\u0642\u0645 \u0627\u0644\u0637\u0628\u064a \u0644\u0634\u0631\u0643\u0629 \u0627\u0646\u0642\u0627\u0630 \u0627\u0644\u062d\u064a\u0627\u0629 \u0627\u0644\u0637\u0628\u064a\u0629\u060c \u0648\u0641\u0642\u064b\u0627 \u0644\u0644\u0623\u0646\u0638\u0645\u0629 \u0648\u0627\u0644\u0644\u0648\u0627\u0626\u062d \u0627\u0644\u0635\u062d\u064a\u0629 \u0627\u0644\u0645\u0639\u0645\u0648\u0644 \u0628\u0647\u0627 \u0641\u064a \u0627\u0644\u0645\u0645\u0644\u0643\u0629 \u0627\u0644\u0639\u0631\u0628\u064a\u0629 \u0627\u0644\u0633\u0639\u0648\u062f\u064a\u0629 \u0648\u0627\u0644\u0645\u0639\u0627\u064a\u064a\u0631 \u0627\u0644\u0645\u0647\u0646\u064a\u0629 \u0627\u0644\u0637\u0628\u064a\u0629 \u0627\u0644\u0645\u0639\u062a\u0645\u062f\u0629. \u0643\u0645\u0627 \u0623\u064f\u062e\u0644\u064a \u0645\u0633\u0624\u0648\u0644\u064a\u0629 \u0645\u0632\u0648\u062f\u064a \u0634\u0631\u0643\u0629 \u0627\u0646\u0642\u0627\u0630 \u0627\u0644\u062d\u064a\u0627\u0629 \u0627\u0644\u0637\u0628\u064a\u0629\u060c \u0648\u0641\u0631\u064a\u0642 \u0627\u0644\u062e\u062f\u0645\u0627\u062a \u0627\u0644\u0637\u0628\u064a\u0629 \u0627\u0644\u0637\u0627\u0631\u0626\u0629 \u0648\u0627\u0644\u0637\u0628\u064a\u0628 \u0627\u0644\u0645\u0639\u0627\u0644\u062c \u0623\u0648 \u0627\u0644\u0627\u0633\u062a\u0634\u0627\u0631\u064a\u060c \u0648\u0627\u0644\u0645\u0646\u0634\u0623\u0629 \u0627\u0644\u0637\u0628\u064a\u0629 \u0627\u0644\u0645\u0633\u062a\u0642\u0628\u0644\u0629 \u0645\u0646 \u0623\u064a \u0645\u0633\u0624\u0648\u0644\u064a\u0629 \u0642\u0627\u0646\u0648\u0646\u064a\u0629.<\/p>\n<p style=\"text-align: right;direction: rtl\"><strong>\u0627\u0644\u0625\u0642\u0631\u0627\u0631 \u0628\u0627\u0644\u0645\u0639\u0644\u0648\u0645\u0627\u062a \u0648\u0627\u0644\u0645\u0648\u0627\u0641\u0642\u0629<\/strong><\/p>\n<p style=\"text-align: right;direction: rtl\">\u0623\u064f\u0642\u0631\u0651 \u0628\u0623\u0646\u0646\u064a \u0642\u062f \u0627\u0637\u0651\u0644\u0639\u062a \u0639\u0644\u0649 \u0627\u0644\u0645\u0639\u0644\u0648\u0645\u0627\u062a \u0627\u0644\u0648\u0627\u0631\u062f\u0629 \u0623\u0639\u0644\u0627\u0647\u060c \u0648\u0641\u0647\u0645\u062a\u0647\u0627\u060c \u0648\u0623\u0648\u0627\u0641\u0642 \u0639\u0644\u0649 \u062a\u0644\u0642\u064a \u0627\u0644\u0639\u0644\u0627\u062c \u0648\u0627\u0644\u062e\u062f\u0645\u0627\u062a \u0627\u0644\u0637\u0628\u064a\u0629 \u0648\u0627\u0644\u0646\u0642\u0644 \u0627\u0644\u0637\u0628\u064a \u062d\u0633\u0628 \u0645\u0627 \u062a\u0645 \u0634\u0631\u062d\u0647 \u0644\u064a.<\/p><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-2\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-2\"><p><strong>Acknowledgment of Refusal of Medical Treatment and\/or Transportation<\/strong><\/p>\n<p>I, the undersigned, acknowledge that I have been offered a medical evaluation, treatment, and\/or transportation to a licensed healthcare facility by certified Emergency Medical Services (EMS) providers. However, I am voluntarily and knowingly refusing all of the services offered by the Emergency Medical Services (EMS) providers. I understand that this refusal may result in serious health consequences, including but not limited to deterioration of my condition, permanent disability, or death.<\/p>\n<p>I further acknowledge that I have been fully informed of the nature and potential risks of refusing treatment and\/or ambulance transportation, and I understand that transportation by any other means may delay access to appropriate medical care and result in adverse outcomes.<\/p>\n\n<p><strong>Release of Liability and Waiver of Claims<\/strong><\/p>\n<p>By signing below, I hereby release and hold harmless the Emergency Medical Services (EMS) providers, the attending or consulting physician, the receiving healthcare facility, and <strong>COMPANY ANKADH AL-HAYYA Medical (LSM)<\/strong> from any and all liability, claims, damages, or legal actions, whether known or unknown, which may arise now or in the future as a result of my refusal of treatment and\/or transportation. This release shall remain binding.<\/p>\n<p>I confirm that I have read and understood the above information and that this decision has been made without coercion.<\/p>\n\n<p style=\"text-align: right;direction: rtl\"><strong>\u0625\u0642\u0631\u0627\u0631 \u0628\u0631\u0641\u0636 \u0627\u0644\u0639\u0644\u0627\u062c \u0648\/\u0623\u0648 \u0627\u0644\u0646\u0642\u0644 \u0627\u0644\u0637\u0628\u064a<\/strong><\/p>\n<p style=\"text-align: right;direction: rtl\">\u0623\u0646\u0627 \u0627\u0644\u0645\u0648\u0642\u0639 \u0623\u062f\u0646\u0627\u0647\u060c \u0623\u064f\u0642\u0631\u0651 \u0628\u0623\u0646\u0647 \u0642\u062f \u062a\u0645 \u0639\u0631\u0636 \u0627\u0644\u062a\u0642\u064a\u064a\u0645 \u0627\u0644\u0637\u0628\u064a\u060c \u0648\u0627\u0644\u0639\u0644\u0627\u062c\u060c \u0648\/\u0623\u0648 \u0627\u0644\u0646\u0642\u0644 \u0625\u0644\u0649 \u0645\u0646\u0634\u0623\u0629 \u0635\u062d\u064a\u0629 \u0645\u0646\u0627\u0633\u0628\u0629 \u0645\u0646 \u0642\u0628\u0644 \u0645\u0632\u0648\u062f\u064a \u0627\u0644\u062e\u062f\u0645\u0627\u062a \u0627\u0644\u0637\u0628\u064a\u0629 \u0627\u0644\u0637\u0627\u0631\u0626\u0629. \u0625\u0644\u0627 \u0623\u0646\u0646\u064a \u0623\u0631\u0641\u0636 \u0637\u0648\u0639\u064b\u0627 \u0648\u0628\u0643\u0627\u0645\u0644 \u0648\u0639\u064a\u064a \u062c\u0645\u064a\u0639 \u0647\u0630\u0647 \u0627\u0644\u062e\u062f\u0645\u0627\u062a \u0627\u0644\u0637\u0628\u064a\u0629 \u0648\/\u0623\u0648 \u0627\u0644\u0646\u0642\u0644 \u0627\u0644\u0637\u0628\u064a. \u0648\u0623\u064f\u062f\u0631\u0643 \u0623\u0646 \u0647\u0630\u0627 \u0627\u0644\u0631\u0641\u0636 \u0642\u062f \u064a\u0624\u062f\u064a \u0625\u0644\u0649 \u0639\u0648\u0627\u0642\u0628 \u0635\u062d\u064a\u0629 \u062e\u0637\u064a\u0631\u0629\u060c \u0628\u0645\u0627 \u0641\u064a \u0630\u0644\u0643 -\u0639\u0644\u0649 \u0633\u0628\u064a\u0644 \u0627\u0644\u0645\u062b\u0627\u0644 \u0644\u0627 \u0627\u0644\u062d\u0635\u0631\u2013 \u062a\u062f\u0647\u0648\u0631 \u0627\u0644\u062d\u0627\u0644\u0629 \u0627\u0644\u0635\u062d\u064a\u0629\u060c \u0623\u0648 \u0627\u0644\u0625\u0639\u0627\u0642\u0629 \u0627\u0644\u062f\u0627\u0626\u0645\u0629\u060c \u0623\u0648 \u0627\u0644\u0648\u0641\u0627\u0629 \u0644\u0627 \u0642\u062f\u0631 \u0627\u0644\u0644\u0647.<\/p>\n<p style=\"text-align: right;direction: rtl\">\u0643\u0645\u0627 \u0623\u064f\u0642\u0631\u0651 \u0628\u0623\u0646\u0647 \u0642\u062f \u062a\u0645 \u0625\u0628\u0644\u0627\u063a\u064a \u0628\u0634\u0643\u0644 \u0643\u0627\u0645\u0644 \u0628\u0637\u0628\u064a\u0639\u0629 \u0648\u0645\u062e\u0627\u0637\u0631 \u0631\u0641\u0636 \u0627\u0644\u0639\u0644\u0627\u062c \u0648\/\u0623\u0648 \u0627\u0644\u0646\u0642\u0644 \u0628\u0633\u064a\u0627\u0631\u0629 \u0627\u0644\u0625\u0633\u0639\u0627\u0641\u060c \u0648\u0623\u062f\u0631\u0643 \u0623\u0646 \u0627\u0644\u0646\u0642\u0644 \u0628\u0648\u0633\u0627\u0626\u0644 \u0623\u062e\u0631\u0649 \u0642\u062f \u064a\u0624\u062f\u064a \u0625\u0644\u0649 \u062a\u0623\u062e\u064a\u0631 \u0641\u064a \u062a\u0644\u0642\u064a \u0627\u0644\u0631\u0639\u0627\u064a\u0629 \u0627\u0644\u0637\u0628\u064a\u0629 \u0627\u0644\u0645\u0646\u0627\u0633\u0628\u0629\u060c \u0645\u0645\u0627 \u0642\u062f \u064a\u0624\u062f\u064a \u0625\u0644\u0649 \u0645\u0636\u0627\u0639\u0641\u0627\u062a \u0635\u062d\u064a\u0629.<\/p>\n\n<p style=\"text-align: right;direction: rtl\"><strong>\u0625\u062e\u0644\u0627\u0621 \u0645\u0633\u0624\u0648\u0644\u064a\u0629 \u0648\u062a\u0646\u0627\u0632\u0644 \u0639\u0646 \u0627\u0644\u0645\u0637\u0627\u0644\u0628\u0627\u062a<\/strong><\/p>\n<p style=\"text-align: right;direction: rtl\">\u0628\u0645\u0648\u062c\u0628 \u062a\u0648\u0642\u064a\u0639\u064a \u0623\u062f\u0646\u0627\u0647\u060c \u0623\u064f\u062e\u0644\u064a \u0627\u0644\u0645\u0633\u0624\u0648\u0644\u064a\u0629 \u0648\u0623\u064f\u0628\u0631\u0626 \u0630\u0645\u0629 \u0645\u0632\u0648\u062f\u064a \u0627\u0644\u062e\u062f\u0645\u0627\u062a \u0627\u0644\u0637\u0628\u064a\u0629 \u0627\u0644\u0637\u0627\u0631\u0626\u0629\u060c \u0648\u0627\u0644\u0637\u0628\u064a\u0628 \u0627\u0644\u0645\u0639\u0627\u0644\u062c \u0623\u0648 \u0627\u0644\u0627\u0633\u062a\u0634\u0627\u0631\u064a\u060c \u0648\u0627\u0644\u0645\u0646\u0634\u0623\u0629 \u0627\u0644\u0635\u062d\u064a\u0629 \u0627\u0644\u0645\u0633\u062a\u0642\u0628\u0644\u0629\u060c \u0648\u0634\u0631\u0643\u0629 <strong>\u0625\u0646\u0642\u0627\u0630 \u0627\u0644\u062d\u064a\u0627\u0629 \u0627\u0644\u0637\u0628\u064a\u0629<\/strong> \u0645\u0646 \u0623\u064a \u0645\u0633\u0624\u0648\u0644\u064a\u0629 \u0623\u0648 \u0645\u0637\u0627\u0644\u0628\u0627\u062a \u0623\u0648 \u0623\u0636\u0631\u0627\u0631 \u0623\u0648 \u0625\u062c\u0631\u0627\u0621\u0627\u062a \u0642\u0627\u0646\u0648\u0646\u064a\u0629 \u2013 \u0633\u0648\u0627\u0621 \u0643\u0627\u0646\u062a \u0645\u0639\u0631\u0648\u0641\u0629 \u0623\u0648 \u063a\u064a\u0631 \u0645\u0639\u0631\u0648\u0641\u0629 \u2013 \u0642\u062f \u062a\u0646\u0634\u0623 \u0627\u0644\u0622\u0646 \u0623\u0648 \u0645\u0633\u062a\u0642\u0628\u0644\u0627\u064b \u0646\u062a\u064a\u062c\u0629 \u0642\u0631\u0627\u0631\u064a \u0628\u0631\u0641\u0636 \u0627\u0644\u0639\u0644\u0627\u062c \u0648\/\u0623\u0648 \u0627\u0644\u0646\u0642\u0644 \u0627\u0644\u0637\u0628\u064a. \u0648\u064a\u0638\u0644 \u0647\u0630\u0627 \u0627\u0644\u0625\u0642\u0631\u0627\u0631 \u0645\u0644\u0632\u0645\u064b\u0627.<\/p>\n<p style=\"text-align: right;direction: rtl\">\u0623\u064f\u0642\u0631 \u0628\u0623\u0646\u0646\u064a \u0642\u062f \u0642\u0631\u0623\u062a \u0648\u0641\u0647\u0645\u062a \u0627\u0644\u0645\u0639\u0644\u0648\u0645\u0627\u062a \u0623\u0639\u0644\u0627\u0647\u060c \u0648\u0623\u0646 \u0647\u0630\u0627 \u0627\u0644\u0642\u0631\u0627\u0631 \u062a\u0645 \u0627\u062a\u062e\u0627\u0630\u0647 \u062f\u0648\u0646 \u0625\u0643\u0631\u0627\u0647 \u0623\u0648 \u0636\u063a\u0637.<\/p><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-5\" class=\"forminator-field-name forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-5_6a2782b49278b\" id=\"forminator-field-name-5_6a2782b49278b-label\" class=\"forminator-label\">Patient or his\/her Guardian<\/label><input type=\"text\" name=\"name-5\" value=\"\" placeholder=\"\u0627\u0644\u0627\u0633\u0645 \u0627\u0644\u062b\u0644\u0627\u062b\u064a\" id=\"forminator-field-name-5_6a2782b49278b\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" autocomplete=\"name\" \/><\/div><\/div><div id=\"text-5\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-5_6a2782b49278b\" id=\"forminator-field-text-5_6a2782b49278b-label\" class=\"forminator-label\">ID\/IQAMA\/ Passport<\/label><input type=\"text\" name=\"text-5\" value=\"\" placeholder=\"E.g. 123456789\" id=\"forminator-field-text-5_6a2782b49278b\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"date-1\" class=\"forminator-field-date forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-1-picker_6a2782b49278b\" id=\"forminator-field-date-1-picker_6a2782b49278b-label\" class=\"forminator-label\">Date of sign<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-1\" value=\"06\/09\/2026\" placeholder=\"Choose Date\" id=\"forminator-field-date-1-picker_6a2782b49278b\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"0\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"phone-1\" class=\"forminator-field-phone forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-1_6a2782b49278b\" id=\"forminator-field-phone-1_6a2782b49278b-label\" class=\"forminator-label\">Phone #<\/label><input type=\"text\" name=\"phone-1\" value=\"\" placeholder=\"E.g. +966 50 1234 123\" id=\"forminator-field-phone-1_6a2782b49278b\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" \/><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"signature-4\" class=\"forminator-field-signature forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-field-signature\"><label for=\"forminator-field-ctlSignature6a2782b4988a5\" id=\"forminator-field-ctlSignature6a2782b4988a5-label\" class=\"forminator-label\">Patient or his\/her Guardian Signature<\/label><div class=\"forminator-signature\" data-elementheight=\"180\"><span id=\"ctlSignature6a2782b4988a5_placeholder\" class=\"forminator-signature--placeholder\" aria-hidden=\"true\">Start signing your signature here<\/span><div id=\"ctlSignature6a2782b4988a5_Container\" class=\"forminator-signature--container\"><canvas id=\"ctlSignature6a2782b4988a5\" class=\"forminator-signature-canvas\" height=\"180\" tabindex=\"-1\"><p>Your browser does not support e-Signature field.<\/p><\/canvas><\/div><\/div><input type=\"hidden\" name=\"field-signature-4\" value=\"6a2782b4988a5\" class=\"signature-prefix\"><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-1\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Signatures<\/h2><hr class=\"forminator-border\" style=\"border: 1px solid #333333;\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-2\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-2_6a2782b49278b\" id=\"forminator-field-name-2_6a2782b49278b-label\" class=\"forminator-label\">ePCR Author Name<\/label><input type=\"text\" name=\"name-2\" value=\"\" placeholder=\"ENTER FULL NAME\" id=\"forminator-field-name-2_6a2782b49278b\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" autocomplete=\"name\" \/><\/div><\/div><div id=\"signature-1\" class=\"forminator-field-signature forminator-col forminator-col-6 \"><div class=\"forminator-field forminator-field-signature\"><label for=\"forminator-field-ctlSignature6a2782b498909\" id=\"forminator-field-ctlSignature6a2782b498909-label\" class=\"forminator-label\">ePCR Author Name<\/label><div class=\"forminator-signature\" data-elementheight=\"180\"><span id=\"ctlSignature6a2782b498909_placeholder\" class=\"forminator-signature--placeholder\" aria-hidden=\"true\">Start signing your signature here<\/span><div id=\"ctlSignature6a2782b498909_Container\" class=\"forminator-signature--container\"><canvas id=\"ctlSignature6a2782b498909\" class=\"forminator-signature-canvas\" height=\"180\" tabindex=\"-1\"><p>Your browser does not support e-Signature field.<\/p><\/canvas><\/div><\/div><input type=\"hidden\" name=\"field-signature-1\" value=\"6a2782b498909\" class=\"signature-prefix\"><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-3\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-3_6a2782b49278b\" id=\"forminator-field-name-3_6a2782b49278b-label\" class=\"forminator-label\">2\u207f\u1d48 Provider Name<\/label><input type=\"text\" name=\"name-3\" value=\"\" placeholder=\"ENTER FULL NAME\" id=\"forminator-field-name-3_6a2782b49278b\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" autocomplete=\"name\" \/><\/div><\/div><div id=\"signature-2\" class=\"forminator-field-signature forminator-col forminator-col-6 \"><div class=\"forminator-field forminator-field-signature\"><label for=\"forminator-field-ctlSignature6a2782b498945\" id=\"forminator-field-ctlSignature6a2782b498945-label\" class=\"forminator-label\">2\u207f\u1d48 Provider Name<\/label><div class=\"forminator-signature\" data-elementheight=\"180\"><span id=\"ctlSignature6a2782b498945_placeholder\" class=\"forminator-signature--placeholder\" aria-hidden=\"true\">Start signing your signature here<\/span><div id=\"ctlSignature6a2782b498945_Container\" class=\"forminator-signature--container\"><canvas id=\"ctlSignature6a2782b498945\" class=\"forminator-signature-canvas\" height=\"180\" tabindex=\"-1\"><p>Your browser does not support e-Signature field.<\/p><\/canvas><\/div><\/div><input type=\"hidden\" name=\"field-signature-2\" value=\"6a2782b498945\" class=\"signature-prefix\"><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-4\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-4_6a2782b49278b\" id=\"forminator-field-name-4_6a2782b49278b-label\" class=\"forminator-label\">Receiving Facility\/Person<\/label><input type=\"text\" name=\"name-4\" value=\"\" placeholder=\"ENTER FULL NAME\" id=\"forminator-field-name-4_6a2782b49278b\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" autocomplete=\"name\" \/><\/div><\/div><div id=\"signature-3\" class=\"forminator-field-signature forminator-col forminator-col-6 \"><div class=\"forminator-field forminator-field-signature\"><label for=\"forminator-field-ctlSignature6a2782b498978\" id=\"forminator-field-ctlSignature6a2782b498978-label\" class=\"forminator-label\">Receiving Facility\/Person Signature<\/label><div class=\"forminator-signature\" data-elementheight=\"180\"><span id=\"ctlSignature6a2782b498978_placeholder\" class=\"forminator-signature--placeholder\" aria-hidden=\"true\">Start signing your signature here<\/span><div id=\"ctlSignature6a2782b498978_Container\" class=\"forminator-signature--container\"><canvas id=\"ctlSignature6a2782b498978\" class=\"forminator-signature-canvas\" height=\"180\" tabindex=\"-1\"><p>Your browser does not support e-Signature field.<\/p><\/canvas><\/div><\/div><input type=\"hidden\" name=\"field-signature-3\" value=\"6a2782b498978\" class=\"signature-prefix\"><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"group-3\" class=\"forminator-field-group forminator-col forminator-col-12 \"><div class=\"forminator-all-group-copies forminator-repeater-field\"><div class=\"forminator-grouped-fields\" data-options=\"{&quot;is_repeater&quot;:true,&quot;min_type&quot;:&quot;custom&quot;,&quot;max_type&quot;:&quot;custom&quot;,&quot;min&quot;:1,&quot;max&quot;:9223372036854775807,&quot;add_text&quot;:&quot;Add item&quot;,&quot;remove_text&quot;:&quot;Remove item&quot;,&quot;action_element_type&quot;:&quot;button&quot;}\"><div class=\"forminator-row\"><div id=\"email-1\" class=\"forminator-field-email forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-email-1_6a2782b49278b\" id=\"forminator-field-email-1_6a2782b49278b-label\" class=\"forminator-label\">Receiving Facility\/Person<\/label><input type=\"email\" name=\"email-1\" value=\"\" placeholder=\"E.g. john@doe.com\" id=\"forminator-field-email-1_6a2782b49278b\" class=\"forminator-input forminator-email--field\" data-required=\"\" aria-required=\"false\" autocomplete=\"email\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"email-2\" class=\"forminator-field-email forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-email-2_6a2782b49278b\" id=\"forminator-field-email-2_6a2782b49278b-label\" class=\"forminator-label\">Email Address<\/label><input type=\"email\" name=\"email-2\" value=\"\" placeholder=\"E.g. john@doe.com\" id=\"forminator-field-email-2_6a2782b49278b\" class=\"forminator-input forminator-email--field\" data-required=\"\" aria-required=\"false\" autocomplete=\"email\" \/><\/div><\/div><\/div><div class=\"forminator-row forminator-action-buttons\"><div class=\"forminator-col forminator-col-12\"><input type=\"button\" value=\"Add item\" class=\"forminator-repeater-action-button forminator-repeater-add\" \/><input type=\"button\" value=\"Remove item\" class=\"forminator-repeater-action-button forminator-repeater-remove\" \/><\/div><\/div><\/div><\/div><\/div><\/div><input type=\"hidden\" name=\"referer_url\" value=\"\" \/><div class=\"forminator-row forminator-row-last\"><div class=\"forminator-col\"><div class=\"forminator-field\"><button class=\"forminator-button forminator-button-submit\">Submit Report<\/button><\/div><\/div><\/div><input type=\"hidden\" id=\"forminator_nonce\" name=\"forminator_nonce\" value=\"59f7bb7b78\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/ar\/wp-json\/wp\/v2\/pages\/614\" \/><input type=\"hidden\" name=\"form_id\" value=\"610\"><input type=\"hidden\" name=\"page_id\" value=\"614\"><input type=\"hidden\" name=\"form_type\" value=\"default\"><input type=\"hidden\" name=\"current_url\" value=\"https:\/\/lsm.sa\/ar\/epcr-events\/\"><input type=\"hidden\" name=\"render_id\" value=\"0\"><input type=\"hidden\" name=\"action\" value=\"forminator_submit_form_custom-forms\"><\/form><\/div>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":3,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-614","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.7 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>ePCR-EVENTS - Life Saver Medical | LSM<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/lsm.sa\/ar\/epcr-events\/\" \/>\n<meta property=\"og:locale\" content=\"ar_AR\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"ePCR-EVENTS - Life Saver Medical | LSM\" \/>\n<meta property=\"og:url\" content=\"https:\/\/lsm.sa\/ar\/epcr-events\/\" \/>\n<meta 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