{"id":435,"date":"2025-12-02T08:00:47","date_gmt":"2025-12-02T09:00:47","guid":{"rendered":"https:\/\/www.dsah.sa\/telemedicine\/?page_id=435"},"modified":"2026-02-01T07:53:04","modified_gmt":"2026-02-01T08:53:04","slug":"mrd","status":"publish","type":"page","link":"https:\/\/www.dsah.sa\/telemedicine\/mrd\/","title":{"rendered":"Medical Report &amp; Medical Information"},"content":{"rendered":"\n\n\n<br>\n<p><span style=\"color: #ff0000;\"><\/span><\/p>\n<h6 style=\"color: #5e9ca0;  text-align: center;\"><strong><span style=\"color: #ff0000;\">Note: The report will be sent E-Mail registered in the hospital <br> \u0645\u0644\u0627\u062d\u0638\u0629: \u0633\u064a\u062a\u0645 \u0625\u0631\u0633\u0627\u0644 \u0627\u0644\u062a\u0642\u0631\u064a\u0631 \u0625\u0644\u0649 \u0627\u0644\u0628\u0631\u064a\u062f \u0627\u0644\u0627\u0644\u0643\u062a\u0631\u0648\u0646\u064a \u0627\u0644\u0645\u0633\u062c\u0644 \u0644\u062f\u064a\u0646\u0627 .<\/span><\/strong> \n<\/h6>\n\n<br>\n\n\n\n<div class=\"wp-block-columns is-layout-flex wp-container-core-columns-is-layout-8f761849 wp-block-columns-is-layout-flex\">\n\n\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\" style=\"flex-basis:80%\"><style id=\"wpforms-css-vars-root\">\n\t\t\t\t:root {\n\t\t\t\t\t--wpforms-field-border-radius: 3px;\n--wpforms-field-border-style: solid;\n--wpforms-field-border-size: 1px;\n--wpforms-field-background-color: #ffffff;\n--wpforms-field-border-color: rgba( 0, 0, 0, 0.25 );\n--wpforms-field-border-color-spare: rgba( 0, 0, 0, 0.25 );\n--wpforms-field-text-color: rgba( 0, 0, 0, 0.7 );\n--wpforms-field-menu-color: #ffffff;\n--wpforms-label-color: rgba( 0, 0, 0, 0.85 );\n--wpforms-label-sublabel-color: rgba( 0, 0, 0, 0.55 );\n--wpforms-label-error-color: #d63637;\n--wpforms-button-border-radius: 3px;\n--wpforms-button-border-style: none;\n--wpforms-button-border-size: 1px;\n--wpforms-button-background-color: #066aab;\n--wpforms-button-border-color: #066aab;\n--wpforms-button-text-color: #ffffff;\n--wpforms-page-break-color: #066aab;\n--wpforms-background-image: none;\n--wpforms-background-position: center center;\n--wpforms-background-repeat: no-repeat;\n--wpforms-background-size: cover;\n--wpforms-background-width: 100px;\n--wpforms-background-height: 100px;\n--wpforms-background-color: rgba( 0, 0, 0, 0 );\n--wpforms-background-url: none;\n--wpforms-container-padding: 0px;\n--wpforms-container-border-style: none;\n--wpforms-container-border-width: 1px;\n--wpforms-container-border-color: #000000;\n--wpforms-container-border-radius: 3px;\n--wpforms-field-size-input-height: 43px;\n--wpforms-field-size-input-spacing: 15px;\n--wpforms-field-size-font-size: 16px;\n--wpforms-field-size-line-height: 19px;\n--wpforms-field-size-padding-h: 14px;\n--wpforms-field-size-checkbox-size: 16px;\n--wpforms-field-size-sublabel-spacing: 5px;\n--wpforms-field-size-icon-size: 1;\n--wpforms-label-size-font-size: 16px;\n--wpforms-label-size-line-height: 19px;\n--wpforms-label-size-sublabel-font-size: 14px;\n--wpforms-label-size-sublabel-line-height: 17px;\n--wpforms-button-size-font-size: 17px;\n--wpforms-button-size-height: 41px;\n--wpforms-button-size-padding-h: 15px;\n--wpforms-button-size-margin-top: 10px;\n--wpforms-container-shadow-size-box-shadow: none;\n\n\t\t\t\t}\n\t\t\t<\/style><style id=\"wpforms-css-vars-397-block-1fc8d186-9ee1-4ba3-8a18-1dd0690ba970\">\n\t\t\t\t#wpforms-397.wpforms-block-1fc8d186-9ee1-4ba3-8a18-1dd0690ba970 {\n\t\t\t\t\t--wpforms-container-padding: 15px;\n--wpforms-button-background-color: #00d084;\n--wpforms-field-size-input-height: 43px;\n--wpforms-field-size-input-spacing: 15px;\n--wpforms-field-size-font-size: 16px;\n--wpforms-field-size-line-height: 19px;\n--wpforms-field-size-padding-h: 14px;\n--wpforms-field-size-checkbox-size: 16px;\n--wpforms-field-size-sublabel-spacing: 5px;\n--wpforms-field-size-icon-size: 1;\n--wpforms-label-size-font-size: 16px;\n--wpforms-label-size-line-height: 19px;\n--wpforms-label-size-sublabel-font-size: 14px;\n--wpforms-label-size-sublabel-line-height: 17px;\n--wpforms-button-size-font-size: 17px;\n--wpforms-button-size-height: 41px;\n--wpforms-button-size-padding-h: 15px;\n--wpforms-button-size-margin-top: 10px;\n--wpforms-container-shadow-size-box-shadow: none;\n\n\t\t\t\t}\n\t\t\t<\/style><style id=\"wpforms-custom-css-397-block-1fc8d186-9ee1-4ba3-8a18-1dd0690ba970\">\n\t\t\t\t.pagelayer-header{\n    display: none;\n}\n\t\t\t<\/style><div class=\"wpforms-container wpforms-container-full wpforms-block wpforms-block-1fc8d186-9ee1-4ba3-8a18-1dd0690ba970 wpforms-render-modern\" id=\"wpforms-397\"><form id=\"wpforms-form-397\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"397\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/telemedicine\/wp-json\/wp\/v2\/pages\/435?wpforms_form_id=397\" data-token=\"1521582527da2f78abe28a0f15a4d1ce\" data-token-time=\"1781748164\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-hidden\" id=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/div><div class=\"wpforms-field-container\"><div id=\"wpforms-397-field_50-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"50\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Request Status \u0627\u0644\u062d\u0627\u0644\u0629 <\/legend><ul id=\"wpforms-397-field_50\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-397-field_50_1\" name=\"wpforms[fields][50]\" value=\"Open\" aria-errormessage=\"wpforms-397-field_50_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-397-field_50_1\">Open<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-397-field_50_2\" name=\"wpforms[fields][50]\" value=\"Close\" aria-errormessage=\"wpforms-397-field_50_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-397-field_50_2\">Close<\/label><\/li><li class=\"choice-3 depth-1 wpforms-selected\"><input type=\"radio\" id=\"wpforms-397-field_50_3\" name=\"wpforms[fields][50]\" value=\"InProgress\" aria-errormessage=\"wpforms-397-field_50_3-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-397-field_50_3\">InProgress<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-397-field_50_4\" name=\"wpforms[fields][50]\" value=\"Re-Open\" aria-errormessage=\"wpforms-397-field_50_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-397-field_50_4\">Re-Open<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-397-field_41-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"41\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">\u0646\u0648\u0639 \u0627\u0644\u0648\u0644\u0627\u062f\u0629<\/legend><ul id=\"wpforms-397-field_41\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-397-field_41_1\" name=\"wpforms[fields][41]\" value=\"\u0637\u0628\u064a\u0639\u064a\" aria-errormessage=\"wpforms-397-field_41_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-397-field_41_1\">\u0637\u0628\u064a\u0639\u064a<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-397-field_41_2\" name=\"wpforms[fields][41]\" value=\"\u0641\u064a\u0635\u0631\u064a\" aria-errormessage=\"wpforms-397-field_41_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-397-field_41_2\">\u0641\u064a\u0635\u0631\u064a<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-397-field_41_3\" name=\"wpforms[fields][41]\" value=\"\u0633\u0642\u0637\" aria-errormessage=\"wpforms-397-field_41_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-397-field_41_3\">\u0633\u0642\u0637<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-397-field_42-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"42\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-397-field_42\">\u0648\u0632\u0646 \u0627\u0644\u0645\u0648\u0644\u0648\u062f <\/label><input type=\"text\" id=\"wpforms-397-field_42\" class=\"wpforms-field-medium\" name=\"wpforms[fields][42]\" aria-errormessage=\"wpforms-397-field_42-error\" ><\/div><div id=\"wpforms-397-field_43-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"43\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-397-field_43\">\u0645\u062f\u0629 \u0627\u0644\u062d\u0645\u0644 \u0628\u0627\u0644\u0627\u0633\u0627\u0628\u064a\u0639<\/label><input type=\"text\" id=\"wpforms-397-field_43\" class=\"wpforms-field-medium\" name=\"wpforms[fields][43]\" aria-errormessage=\"wpforms-397-field_43-error\" ><\/div><div id=\"wpforms-397-field_44-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"44\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-397-field_44\">\u0641\u0635\u064a\u0644\u0629 \u0627\u0644\u062f\u0645 <\/label><input type=\"text\" id=\"wpforms-397-field_44\" class=\"wpforms-field-medium\" name=\"wpforms[fields][44]\" aria-errormessage=\"wpforms-397-field_44-error\" ><\/div><div id=\"wpforms-397-field_45-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"45\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-397-field_45\">\u0631\u0642\u0645 \u0645\u0644\u0641 \u0627\u0644\u0627\u0645<\/label><input type=\"text\" id=\"wpforms-397-field_45\" class=\"wpforms-field-medium\" name=\"wpforms[fields][45]\" aria-errormessage=\"wpforms-397-field_45-error\" ><\/div><div id=\"wpforms-397-field_46-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"46\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-397-field_46\">\u0631\u0642\u0645 \u0645\u0644\u0641 \u0627\u0644\u0637\u0641\u0644<\/label><input type=\"text\" id=\"wpforms-397-field_46\" class=\"wpforms-field-medium\" name=\"wpforms[fields][46]\" aria-errormessage=\"wpforms-397-field_46-error\" ><\/div><div id=\"wpforms-397-field_47-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"47\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">\u0633\u0627\u0639\u0629 \u0627\u0644\u0648\u0644\u0627\u062f\u0629<\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-date-type-datepicker\"><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-397-field_47\" class=\"wpforms-field-date-time-date wpforms-datepicker\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][47][date]\" aria-errormessage=\"wpforms-397-field_47-error\" ><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><label for=\"wpforms-397-field_47\" class=\"wpforms-field-sublabel after\">Date<\/label><\/div><div class=\"wpforms-field-row-block\"><input type=\"text\" id=\"wpforms-397-field_47-time\" class=\"wpforms-field-date-time-time wpforms-timepicker\" data-time-format=\"g:i A\" data-step=\"30\" data-rule-time12h=\"true\" name=\"wpforms[fields][47][time]\" aria-errormessage=\"wpforms-397-field_47-time-error\" ><label for=\"wpforms-397-field_47-time\" class=\"wpforms-field-sublabel after\">Time<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-397-field_49-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"49\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-397-field_49\">\u0627\u0644\u0645\u0648\u0638\u0641 \u0627\u0644\u0645\u062e\u062a\u0635<\/label><input type=\"text\" id=\"wpforms-397-field_49\" class=\"wpforms-field-medium\" name=\"wpforms[fields][49]\" aria-errormessage=\"wpforms-397-field_49-error\" ><\/div><div id=\"wpforms-397-field_48-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"48\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">\u062a\u0627\u0631\u064a\u062e \u0627\u0644\u0627\u0633\u062a\u0644\u0627\u0645<\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-date-type-datepicker\"><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-397-field_48\" class=\"wpforms-field-date-time-date wpforms-datepicker\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][48][date]\" aria-errormessage=\"wpforms-397-field_48-error\" ><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><label for=\"wpforms-397-field_48\" class=\"wpforms-field-sublabel after\">Date<\/label><\/div><div class=\"wpforms-field-row-block\"><input type=\"text\" id=\"wpforms-397-field_48-time\" class=\"wpforms-field-date-time-time wpforms-timepicker\" data-time-format=\"g:i A\" data-step=\"30\" data-rule-time12h=\"true\" name=\"wpforms[fields][48][time]\" aria-errormessage=\"wpforms-397-field_48-time-error\" ><label for=\"wpforms-397-field_48-time\" class=\"wpforms-field-sublabel after\">Time<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-397-field_1-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"1\"><fieldset><legend class=\"wpforms-field-label\">To Request Medical Report \u0623\u062e\u062a\u0631 \u0646\u0648\u0639 \u0627\u0644\u062e\u062f\u0645\u0629  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-397-field_1\" class=\"wpforms-field-required\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-397-field_1_4\" name=\"wpforms[fields][1]\" value=\"\u0627\u0644\u062a\u0642\u0627\u0631\u064a\u0631 \u0627\u0644\u0637\u0628\u064a\u0629 Medical Report\" aria-errormessage=\"wpforms-397-field_1_4-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-397-field_1_4\">\u0627\u0644\u062a\u0642\u0627\u0631\u064a\u0631 \u0627\u0644\u0637\u0628\u064a\u0629 Medical Report<\/label><\/li><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-397-field_1_1\" name=\"wpforms[fields][1]\" value=\"\u0627\u0644\u0625\u062c\u0627\u0632\u0627\u062a \u0627\u0644\u0645\u0631\u0636\u064a\u0629 Sick Leave\" aria-errormessage=\"wpforms-397-field_1_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-397-field_1_1\">\u0627\u0644\u0625\u062c\u0627\u0632\u0627\u062a \u0627\u0644\u0645\u0631\u0636\u064a\u0629 Sick Leave<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"radio\" id=\"wpforms-397-field_1_9\" name=\"wpforms[fields][1]\" value=\"\u0625\u062c\u0627\u0632\u0629 \u0645\u0631\u0627\u0641\u0642 Companion Sick Leave\" aria-errormessage=\"wpforms-397-field_1_9-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-397-field_1_9\">\u0625\u062c\u0627\u0632\u0629 \u0645\u0631\u0627\u0641\u0642 Companion Sick Leave<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-397-field_1_3\" name=\"wpforms[fields][1]\" value=\"\u0628\u0644\u0627\u063a\u0627\u062a \u0627\u0644\u0648\u0644\u0627\u062f\u0629 Birth Certificate\" aria-errormessage=\"wpforms-397-field_1_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-397-field_1_3\">\u0628\u0644\u0627\u063a\u0627\u062a \u0627\u0644\u0648\u0644\u0627\u062f\u0629 Birth Certificate<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"radio\" id=\"wpforms-397-field_1_8\" name=\"wpforms[fields][1]\" value=\"\u0645\u0634\u0647\u062f \u062d\u0636\u0648\u0631 Declaration of Attendance\" aria-errormessage=\"wpforms-397-field_1_8-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-397-field_1_8\">\u0645\u0634\u0647\u062f \u062d\u0636\u0648\u0631 Declaration of Attendance<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"radio\" id=\"wpforms-397-field_1_10\" name=\"wpforms[fields][1]\" value=\"\u0627\u062c\u0627\u0632\u0629 \u0627\u0644\u0623\u0645\u0648\u0645\u0629 Maternity Leave\" aria-errormessage=\"wpforms-397-field_1_10-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-397-field_1_10\">\u0627\u062c\u0627\u0632\u0629 \u0627\u0644\u0623\u0645\u0648\u0645\u0629 Maternity Leave<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"radio\" id=\"wpforms-397-field_1_11\" name=\"wpforms[fields][1]\" value=\"\u0627\u062c\u0627\u0632\u0629 \u0627\u0644\u0623\u0628\u0648\u0629 Paternity Leave\" aria-errormessage=\"wpforms-397-field_1_11-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-397-field_1_11\">\u0627\u062c\u0627\u0632\u0629 \u0627\u0644\u0623\u0628\u0648\u0629 Paternity Leave<\/label><\/li><li class=\"choice-12 depth-1\"><input type=\"radio\" id=\"wpforms-397-field_1_12\" name=\"wpforms[fields][1]\" value=\"\u062e\u0627\u0635 \u0628\u0645\u0648\u0638\u0641\u064a \u0627\u0644\u0645\u0633\u062a\u0634\u0641\u0649\" aria-errormessage=\"wpforms-397-field_1_12-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-397-field_1_12\">\u062e\u0627\u0635 \u0628\u0645\u0648\u0638\u0641\u064a \u0627\u0644\u0645\u0633\u062a\u0634\u0641\u0649<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-397-field_70-container\" class=\"wpforms-field wpforms-field-html wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"70\" style=\"display:none;\"><div id=\"wpforms-397-field_70\" aria-errormessage=\"wpforms-397-field_70-error\"><p><span style=\"color: #ff0000;\"><\/span><\/p>\r\n<p style=\"color: #5e9ca0; note\u200b: Companion Notification \u200bis granted only to the name registered at the admissions office. \u200bThe report will only be generated during the presence of the companion at the medical reports office during the accommodation period .\u200bKindly bring your National ID \/Iqama for validation.\u200b;\"><span style=\"color: #ff0000;\">Note\u200b: Companion Notification \u200bis granted only to the name registered at the admissions office. \u200bThe report will only be generated during the presence of the companion at the medical reports office during the accommodation period .\u200b<\/span><br \/><span style=\"color: #ff0000;\">Kindly bring your National ID \/<\/span><br \/><span style=\"color: #ff0000;\">Iqama for validation.\u200b&nbsp;<\/span><\/p>\r\n<p style=\"color: #5e9ca0; note\u200b: Companion Notification \u200bis granted only to the name registered at the admissions office. \u200bThe report will only be generated during the presence of the companion at the medical reports office during the accommodation period .\u200bKindly bring your National ID \/Iqama for validation.\u200b;\"><span style=\"color: #ff0000;\">\u0645\u0644\u0627\u062d\u0638\u0629: \u064a\u064f\u0645\u0646\u062d \u0625\u0634\u0639\u0627\u0631 \u0627\u0644\u0645\u0631\u0627\u0641\u0642 \u0641\u0642\u0637 \u0644\u0644\u0627\u0633\u0645 \u0627\u0644\u0645\u0633\u062c\u0644 \u0641\u064a \u0645\u0643\u062a\u0628 \u0627\u0644\u062f\u062e\u0648\u0644. \u0648\u0644\u0646 \u064a\u064f\u0635\u062f\u0631 \u0627\u0644\u062a\u0642\u0631\u064a\u0631 \u0625\u0644\u0627 \u0628\u062d\u0636\u0648\u0631 \u0627\u0644\u0645\u0631\u0627\u0641\u0642 \u0641\u064a \u0645\u0643\u062a\u0628 \u0627\u0644\u062a\u0642\u0627\u0631\u064a\u0631 \u0627\u0644\u0637\u0628\u064a\u0629 \u062e\u0644\u0627\u0644 \u0641\u062a\u0631\u0629 \u0627\u0644\u0625\u0642\u0627\u0645\u0629.<br \/>\u064a\u0631\u062c\u0649 \u0625\u062d\u0636\u0627\u0631 \u0628\u0637\u0627\u0642\u0629 \u0627\u0644\u0647\u0648\u064a\u0629 \u0627\u0644\u0648\u0637\u0646\u064a\u0629\/\u0627\u0644\u0625\u0642\u0627\u0645\u0629 \u0644\u0644\u062a\u062d\u0642\u0642.<\/span><\/p><\/div><\/div><div id=\"wpforms-397-field_75-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show wpforms-conditional-trigger\" data-field-id=\"75\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-397-field_75\">Name &#8211; Staff ID  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-397-field_75\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][75]\" aria-errormessage=\"wpforms-397-field_75-error\" required><\/div><div id=\"wpforms-397-field_84-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"84\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">To Request Medical Report \u0623\u062e\u062a\u0631 \u0646\u0648\u0639 \u0627\u0644\u062e\u062f\u0645\u0629  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-397-field_84\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-397-field_84_1\" name=\"wpforms[fields][84][]\" value=\"\u0627\u0644\u062a\u0642\u0627\u0631\u064a\u0631 \u0627\u0644\u0637\u0628\u064a\u0629 Medical Report\" aria-errormessage=\"wpforms-397-field_84_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-397-field_84_1\">\u0627\u0644\u062a\u0642\u0627\u0631\u064a\u0631 \u0627\u0644\u0637\u0628\u064a\u0629 Medical Report<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-397-field_84_2\" name=\"wpforms[fields][84][]\" value=\"\u0627\u0644\u0625\u062c\u0627\u0632\u0627\u062a \u0627\u0644\u0645\u0631\u0636\u064a\u0629 Sick Leave\" aria-errormessage=\"wpforms-397-field_84_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-397-field_84_2\">\u0627\u0644\u0625\u062c\u0627\u0632\u0627\u062a \u0627\u0644\u0645\u0631\u0636\u064a\u0629 Sick Leave<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-397-field_84_3\" name=\"wpforms[fields][84][]\" value=\"\u0625\u062c\u0627\u0632\u0629 \u0645\u0631\u0627\u0641\u0642 Companion Sick Leave\" aria-errormessage=\"wpforms-397-field_84_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-397-field_84_3\">\u0625\u062c\u0627\u0632\u0629 \u0645\u0631\u0627\u0641\u0642 Companion Sick Leave<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-397-field_84_4\" name=\"wpforms[fields][84][]\" value=\"\u0628\u0644\u0627\u063a\u0627\u062a \u0627\u0644\u0648\u0644\u0627\u062f\u0629 Birth Certificate\" aria-errormessage=\"wpforms-397-field_84_4-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-397-field_84_4\">\u0628\u0644\u0627\u063a\u0627\u062a \u0627\u0644\u0648\u0644\u0627\u062f\u0629 Birth Certificate<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-397-field_84_5\" name=\"wpforms[fields][84][]\" value=\"\u0645\u0634\u0647\u062f \u062d\u0636\u0648\u0631 Declaration of Attendance\" aria-errormessage=\"wpforms-397-field_84_5-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-397-field_84_5\">\u0645\u0634\u0647\u062f \u062d\u0636\u0648\u0631 Declaration of Attendance<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-397-field_84_6\" name=\"wpforms[fields][84][]\" value=\"\u0627\u062c\u0627\u0632\u0629 \u0627\u0644\u0623\u0645\u0648\u0645\u0629 Maternity Leave\" aria-errormessage=\"wpforms-397-field_84_6-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-397-field_84_6\">\u0627\u062c\u0627\u0632\u0629 \u0627\u0644\u0623\u0645\u0648\u0645\u0629 Maternity Leave<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-397-field_84_7\" name=\"wpforms[fields][84][]\" value=\"\u0627\u062c\u0627\u0632\u0629 \u0627\u0644\u0623\u0628\u0648\u0629 Paternity Leave\" aria-errormessage=\"wpforms-397-field_84_7-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-397-field_84_7\">\u0627\u062c\u0627\u0632\u0629 \u0627\u0644\u0623\u0628\u0648\u0629 Paternity Leave<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-397-field_9-container\" class=\"wpforms-field wpforms-field-layout wpforms-conditional-field wpforms-conditional-hide\" data-field-id=\"9\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-397-field_2-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"2\"><label class=\"wpforms-field-label\" for=\"wpforms-397-field_2\">Patient\u2019s Name \u0627\u0633\u0645 \u0627\u0644\u0645\u0631\u064a\u0636  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-397-field_2\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][2]\" aria-errormessage=\"wpforms-397-field_2-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-397-field_3-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"3\"><label class=\"wpforms-field-label\" for=\"wpforms-397-field_3\">File Number \/ ID Number \u0631\u0642\u0645 \u0627\u0644\u0645\u0644\u0641 \u0627\u0644\u0637\u0628\u064a \/ \u0627\u0644\u0647\u0648\u064a\u0629   <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-397-field_3\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][3]\" aria-errormessage=\"wpforms-397-field_3-error\" required><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-397-field_5-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"5\"><label class=\"wpforms-field-label\" for=\"wpforms-397-field_5\">Date Of Visit \u062a\u0627\u0631\u064a\u062e \u0627\u0644\u0632\u064a\u0627\u0631\u0629 <\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-397-field_5\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][5][date]\" aria-errormessage=\"wpforms-397-field_5-error\" ><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-397-field_6-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"6\"><label class=\"wpforms-field-label\" for=\"wpforms-397-field_6\">Doctor\u2019s Name  \u0627\u0633\u0645 \u0627\u0644\u0637\u0628\u064a\u0628 <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-397-field_6\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][6]\" aria-errormessage=\"wpforms-397-field_6-error\" required><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-397-field_7-container\" class=\"wpforms-field wpforms-field-email wpforms-conditional-trigger\" data-field-id=\"7\"><label class=\"wpforms-field-label\" for=\"wpforms-397-field_7\">Email \u0627\u0644\u0627\u064a\u0645\u064a\u0644  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-397-field_7\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][7]\" spellcheck=\"false\" aria-errormessage=\"wpforms-397-field_7-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-397-field_8-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"8\"><label class=\"wpforms-field-label\" for=\"wpforms-397-field_8\">Mobile Number \u0631\u0642\u0645 \u0627\u0644\u062c\u0648\u0627\u0644  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-397-field_8\" class=\"wpforms-field-medium wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][8]\" aria-label=\"Mobile Number \u0631\u0642\u0645 \u0627\u0644\u062c\u0648\u0627\u0644 \" aria-errormessage=\"wpforms-397-field_8-error\" required><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-397-field_76-container\" class=\"wpforms-field wpforms-field-layout wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"76\" style=\"display:none;\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-397-field_77-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"77\"><label class=\"wpforms-field-label\" for=\"wpforms-397-field_77\">Patient\u2019s Name \u0627\u0633\u0645 \u0627\u0644\u0645\u0631\u064a\u0636   <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-397-field_77\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][77]\" aria-errormessage=\"wpforms-397-field_77-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-397-field_80-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"80\"><label class=\"wpforms-field-label\" for=\"wpforms-397-field_80\">File Number \/ ID Number \u0631\u0642\u0645 \u0627\u0644\u0645\u0644\u0641 \u0627\u0644\u0637\u0628\u064a \/ \u0627\u0644\u0647\u0648\u064a\u0629   <\/label><input type=\"text\" id=\"wpforms-397-field_80\" class=\"wpforms-field-small\" name=\"wpforms[fields][80]\" aria-errormessage=\"wpforms-397-field_80-error\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-397-field_78-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"78\"><label class=\"wpforms-field-label\" for=\"wpforms-397-field_78\">Date Of Visit \u062a\u0627\u0631\u064a\u062e \u0627\u0644\u0632\u064a\u0627\u0631\u0629  <\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-397-field_78\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][78][date]\" aria-errormessage=\"wpforms-397-field_78-error\" ><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-397-field_81-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"81\"><label class=\"wpforms-field-label\" for=\"wpforms-397-field_81\">Doctor\u2019s Name  \u0627\u0633\u0645 \u0627\u0644\u0637\u0628\u064a\u0628 <\/label><input type=\"text\" id=\"wpforms-397-field_81\" class=\"wpforms-field-medium\" name=\"wpforms[fields][81]\" aria-errormessage=\"wpforms-397-field_81-error\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-397-field_79-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"79\"><label class=\"wpforms-field-label\" for=\"wpforms-397-field_79\">Email \u0627\u0644\u0627\u064a\u0645\u064a\u0644 <\/label><input type=\"email\" id=\"wpforms-397-field_79\" class=\"wpforms-field-medium\" name=\"wpforms[fields][79]\" spellcheck=\"false\" aria-errormessage=\"wpforms-397-field_79-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-397-field_82-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"82\"><label class=\"wpforms-field-label\" for=\"wpforms-397-field_82\">Mobile Number \u0631\u0642\u0645 \u0627\u0644\u062c\u0648\u0627\u0644  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-397-field_82\" class=\"wpforms-field-medium wpforms-field-required\" data-rule-int-phone-field=\"true\" name=\"wpforms[fields][82]\" aria-label=\"Mobile Number \u0631\u0642\u0645 \u0627\u0644\u062c\u0648\u0627\u0644 \" aria-errormessage=\"wpforms-397-field_82-error\" required><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-397-field_85-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"85\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-397-field_85\">Comments <\/label><textarea id=\"wpforms-397-field_85\" class=\"wpforms-field-medium\" name=\"wpforms[fields][85]\" aria-errormessage=\"wpforms-397-field_85-error\" ><\/textarea><\/div><div id=\"wpforms-397-field_56-container\" class=\"wpforms-field wpforms-field-layout wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"56\" style=\"display:none;\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-397-field_57-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"57\"><label class=\"wpforms-field-label\" for=\"wpforms-397-field_57\">Companion \u2019s Name \u0627\u0633\u0645 \u0627\u0644\u0645\u0631\u0627\u0641\u0642  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-397-field_57\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][57]\" aria-errormessage=\"wpforms-397-field_57-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-397-field_60-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"60\"><label class=\"wpforms-field-label\" for=\"wpforms-397-field_60\">File Number \/ ID Number \u0631\u0642\u0645 \u0627\u0644\u0645\u0644\u0641 \u0627\u0644\u0637\u0628\u064a \/ \u0627\u0644\u0647\u0648\u064a\u0629    <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-397-field_60\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][60]\" aria-errormessage=\"wpforms-397-field_60-error\" required><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-397-field_58-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"58\"><label class=\"wpforms-field-label\" for=\"wpforms-397-field_58\">Date of Birth \u062a\u0627\u0631\u064a\u062e \u0627\u0644\u0645\u064a\u0644\u0627\u062f <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-397-field_58\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][58][date]\" aria-errormessage=\"wpforms-397-field_58-error\" required><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-397-field_61-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"61\"><label class=\"wpforms-field-label\" for=\"wpforms-397-field_61\">Relation to Kinship \u0635\u0644\u0629 \u0627\u0644\u0642\u0631\u0627\u0628\u0629 <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-397-field_61\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][61]\" aria-errormessage=\"wpforms-397-field_61-error\" required><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-397-field_59-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"59\"><label class=\"wpforms-field-label\" for=\"wpforms-397-field_59\">Email \u0627\u0644\u0627\u064a\u0645\u064a\u0644 <\/label><input type=\"email\" id=\"wpforms-397-field_59\" class=\"wpforms-field-medium\" name=\"wpforms[fields][59]\" spellcheck=\"false\" aria-errormessage=\"wpforms-397-field_59-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-397-field_62-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"62\"><label class=\"wpforms-field-label\" for=\"wpforms-397-field_62\">Mobile Number \u0631\u0642\u0645 \u0627\u0644\u062c\u0648\u0627\u0644   <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-397-field_62\" class=\"wpforms-field-medium wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][62]\" aria-label=\"Mobile Number \u0631\u0642\u0645 \u0627\u0644\u062c\u0648\u0627\u0644  \" aria-errormessage=\"wpforms-397-field_62-error\" required><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-397-field_63-container\" class=\"wpforms-field wpforms-field-layout wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"63\" style=\"display:none;\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-397-field_64-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"64\"><label class=\"wpforms-field-label\" for=\"wpforms-397-field_64\">Visitor\u2019s Name \u0627\u0633\u0645 \u0627\u0644\u0645\u0631\u0627\u0641\u0642   <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-397-field_64\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][64]\" aria-errormessage=\"wpforms-397-field_64-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-397-field_67-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"67\"><label class=\"wpforms-field-label\" for=\"wpforms-397-field_67\">File Number \/ ID Number \u0631\u0642\u0645 \u0627\u0644\u0645\u0644\u0641 \u0627\u0644\u0637\u0628\u064a \/ \u0627\u0644\u0647\u0648\u064a\u0629     <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-397-field_67\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][67]\" aria-errormessage=\"wpforms-397-field_67-error\" required><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-397-field_65-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"65\"><label class=\"wpforms-field-label\" for=\"wpforms-397-field_65\">Date of Birth \u062a\u0627\u0631\u064a\u062e \u0627\u0644\u0645\u064a\u0644\u0627\u062f <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-397-field_65\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][65][date]\" aria-errormessage=\"wpforms-397-field_65-error\" required><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-397-field_68-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"68\"><label class=\"wpforms-field-label\" for=\"wpforms-397-field_68\">Relation to Kinship \u0635\u0644\u0629 \u0627\u0644\u0642\u0631\u0627\u0628\u0629 <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-397-field_68\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][68]\" aria-errormessage=\"wpforms-397-field_68-error\" required><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-397-field_66-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"66\"><label class=\"wpforms-field-label\" for=\"wpforms-397-field_66\">Email \u0627\u0644\u0627\u064a\u0645\u064a\u0644  <\/label><input type=\"email\" id=\"wpforms-397-field_66\" class=\"wpforms-field-medium\" name=\"wpforms[fields][66]\" spellcheck=\"false\" aria-errormessage=\"wpforms-397-field_66-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-397-field_69-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"69\"><label class=\"wpforms-field-label\" for=\"wpforms-397-field_69\">Mobile Number \u0631\u0642\u0645 \u0627\u0644\u062c\u0648\u0627\u0644   <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-397-field_69\" class=\"wpforms-field-medium wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][69]\" aria-label=\"Mobile Number \u0631\u0642\u0645 \u0627\u0644\u062c\u0648\u0627\u0644  \" aria-errormessage=\"wpforms-397-field_69-error\" required><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-397-field_14-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-field wpforms-conditional-show wpforms-conditional-trigger\" data-field-id=\"14\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">SEHA Platform \u0627\u0631\u0633\u0627\u0644 \u0627\u0644\u062a\u0642\u0631\u064a\u0631  \u0644\u0645\u0646\u0635\u0629 \u0635\u062d\u0629 \u0627\u0644\u0633\u0639\u0648\u062f\u064a \u0627\u0644\u0627\u0644\u0643\u062a\u0631\u0648\u0646\u064a  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-397-field_14\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-397-field_14_1\" name=\"wpforms[fields][14]\" value=\"Yes\" aria-errormessage=\"wpforms-397-field_14_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-397-field_14_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-397-field_14_2\" name=\"wpforms[fields][14]\" value=\"No\" aria-errormessage=\"wpforms-397-field_14_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-397-field_14_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-397-field_51-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"51\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-397-field_52-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"52\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Select Language \u0627\u062e\u062a\u0631 \u0627\u0644\u0644\u063a\u0629 <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-397-field_52\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-397-field_52_1\" name=\"wpforms[fields][52]\" value=\"Arabic \u0639\u0631\u0628\u064a\" aria-errormessage=\"wpforms-397-field_52_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-397-field_52_1\">Arabic \u0639\u0631\u0628\u064a<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-397-field_52_2\" name=\"wpforms[fields][52]\" value=\"English \u0627\u0646\u062c\u0644\u064a\u0632\u064a\" aria-errormessage=\"wpforms-397-field_52_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-397-field_52_2\">English \u0627\u0646\u062c\u0644\u064a\u0632\u064a<\/label><\/li><\/ul><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-397-field_53-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"53\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Select Type \u062d\u062f\u062f \u0627\u0644\u0646\u0648\u0639 <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-397-field_53\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-397-field_53_1\" name=\"wpforms[fields][53]\" value=\"Short \u0645\u062e\u062a\u0635\u0631\" aria-errormessage=\"wpforms-397-field_53_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-397-field_53_1\">Short \u0645\u062e\u062a\u0635\u0631<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-397-field_53_2\" name=\"wpforms[fields][53]\" value=\"Details \u0645\u0641\u0635\u0644\" aria-errormessage=\"wpforms-397-field_53_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-397-field_53_2\">Details \u0645\u0641\u0635\u0644<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-397-field_12-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"12\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-397-field_12\">Note \u0645\u0644\u0627\u062d\u0638\u0629 <\/label><textarea id=\"wpforms-397-field_12\" class=\"wpforms-field-medium\" name=\"wpforms[fields][12]\" aria-errormessage=\"wpforms-397-field_12-error\" ><\/textarea><\/div><div id=\"wpforms-397-field_13-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-conditional-field wpforms-conditional-hide\" data-field-id=\"13\"><fieldset><legend class=\"wpforms-field-label\">Consent \u0645\u0648\u0627\u0641\u0642\u0629 <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-397-field_13\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-397-field_13_1\" name=\"wpforms[fields][13][]\" value=\"I acknowledge that I bear full responsibility for the security of the email address provided above. In the event of hacking or misuse, the hospital will not be held liable for any data breaches resulting from such incidents \u0623\u0642\u0631 \u0628\u062a\u062d\u0645\u0644\u064a \u0627\u0644\u0645\u0633\u0624\u0648\u0644\u064a\u0629 \u0627\u0644\u0643\u0627\u0645\u0644\u0629 \u0639\u0646 \u0623\u0645\u0627\u0646 \u0639\u0646\u0648\u0627\u0646 \u0627\u0644\u0628\u0631\u064a\u062f \u0627\u0644\u0625\u0644\u0643\u062a\u0631\u0648\u0646\u064a \u0627\u0644\u0645\u0630\u0643\u0648\u0631 \u0623\u0639\u0644\u0627\u0647. \u0641\u064a \u062d\u0627\u0644 \u062d\u062f\u0648\u062b \u0627\u062e\u062a\u0631\u0627\u0642 \u0623\u0648 \u0625\u0633\u0627\u0621\u0629 \u0627\u0633\u062a\u062e\u062f\u0627\u0645\u060c \u0644\u0646 \u064a\u0643\u0648\u0646 \u0627\u0644\u0645\u0633\u062a\u0634\u0641\u0649 \u0645\u0633\u0624\u0648\u0644\u0627\u064b \u0639\u0646 \u0623\u064a \u0627\u062e\u062a\u0631\u0627\u0642 \u0644\u0644\u0628\u064a\u0627\u0646\u0627\u062a \u0646\u0627\u062a\u062c \u0639\u0646 \u0645\u062b\u0644 \u0647\u0630\u0647 \u0627\u0644\u062d\u0648\u0627\u062f\u062b.\" aria-errormessage=\"wpforms-397-field_13_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-397-field_13_1\">I acknowledge that I bear full responsibility for the security of the email address provided above. In the event of hacking or misuse, the hospital will not be held liable for any data breaches resulting from such incidents \u0623\u0642\u0631 \u0628\u062a\u062d\u0645\u0644\u064a \u0627\u0644\u0645\u0633\u0624\u0648\u0644\u064a\u0629 \u0627\u0644\u0643\u0627\u0645\u0644\u0629 \u0639\u0646 \u0623\u0645\u0627\u0646 \u0639\u0646\u0648\u0627\u0646 \u0627\u0644\u0628\u0631\u064a\u062f \u0627\u0644\u0625\u0644\u0643\u062a\u0631\u0648\u0646\u064a \u0627\u0644\u0645\u0630\u0643\u0648\u0631 \u0623\u0639\u0644\u0627\u0647. \u0641\u064a \u062d\u0627\u0644 \u062d\u062f\u0648\u062b \u0627\u062e\u062a\u0631\u0627\u0642 \u0623\u0648 \u0625\u0633\u0627\u0621\u0629 \u0627\u0633\u062a\u062e\u062f\u0627\u0645\u060c \u0644\u0646 \u064a\u0643\u0648\u0646 \u0627\u0644\u0645\u0633\u062a\u0634\u0641\u0649 \u0645\u0633\u0624\u0648\u0644\u0627\u064b \u0639\u0646 \u0623\u064a \u0627\u062e\u062a\u0631\u0627\u0642 \u0644\u0644\u0628\u064a\u0627\u0646\u0627\u062a \u0646\u0627\u062a\u062c \u0639\u0646 \u0645\u062b\u0644 \u0647\u0630\u0647 \u0627\u0644\u062d\u0648\u0627\u062f\u062b.<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-397-field_15-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"15\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Acknowledge of the accuracy of the information \u0627\u0644\u0625\u0642\u0631\u0627\u0631 \u0628\u062f\u0642\u0629 \u0627\u0644\u0645\u0639\u0644\u0648\u0645\u0627\u062a <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-397-field_15\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-397-field_15_1\" name=\"wpforms[fields][15][]\" value=\"I acknowledge that the above-mentioned information is correct , It will be used to access the SEHA sick leave Platform \u0623\u0642\u0631 \u0628\u0623\u0646 \u0627\u0644\u0645\u0639\u0644\u0648\u0645\u0627\u062a \u0627\u0644\u0645\u0630\u0643\u0648\u0631\u0629 \u0623\u0639\u0644\u0627\u0647 \u0635\u062d\u064a\u062d\u0629 \u0648\u0633\u064a\u062a\u0645 \u0627\u0633\u062a\u062e\u062f\u0627\u0645\u0647\u0627 \u0644\u0644\u0648\u0635\u0648\u0644 \u0625\u0644\u0649 \u0645\u0646\u0635\u0629 \u0625\u062c\u0627\u0632\u0627\u062a \u0627\u0644\u0645\u0631\u0636\u064a\u0629 \u0627\u0644\u062a\u0627\u0628\u0639\u0629 \u0635\u062d\u0629\" aria-errormessage=\"wpforms-397-field_15_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-397-field_15_1\">I acknowledge that the above-mentioned information is correct , It will be used to access the SEHA sick leave Platform \u0623\u0642\u0631 \u0628\u0623\u0646 \u0627\u0644\u0645\u0639\u0644\u0648\u0645\u0627\u062a \u0627\u0644\u0645\u0630\u0643\u0648\u0631\u0629 \u0623\u0639\u0644\u0627\u0647 \u0635\u062d\u064a\u062d\u0629 \u0648\u0633\u064a\u062a\u0645 \u0627\u0633\u062a\u062e\u062f\u0627\u0645\u0647\u0627 \u0644\u0644\u0648\u0635\u0648\u0644 \u0625\u0644\u0649 \u0645\u0646\u0635\u0629 \u0625\u062c\u0627\u0632\u0627\u062a \u0627\u0644\u0645\u0631\u0636\u064a\u0629 \u0627\u0644\u062a\u0627\u0628\u0639\u0629 \u0635\u062d\u0629<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-397-field_16-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-field wpforms-conditional-show wpforms-conditional-trigger\" data-field-id=\"16\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Newborn \u0639\u062f\u062f \u0627\u0644\u0645\u0648\u0627\u0644\u064a\u062f \u0627\u0644\u062c\u062f\u062f <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-397-field_16\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-397-field_16_1\" name=\"wpforms[fields][16]\" value=\"Single \u0637\u0641\u0644\" aria-errormessage=\"wpforms-397-field_16_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-397-field_16_1\">Single \u0637\u0641\u0644<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-397-field_16_2\" name=\"wpforms[fields][16]\" value=\"Twins \u0637\u0641\u0644\u064a\u0646\" aria-errormessage=\"wpforms-397-field_16_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-397-field_16_2\">Twins \u0637\u0641\u0644\u064a\u0646<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-397-field_16_3\" name=\"wpforms[fields][16]\" value=\"Triples \u062b\u0644\u0627\u062b \u0627\u0637\u0641\u0627\u0644\" aria-errormessage=\"wpforms-397-field_16_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-397-field_16_3\">Triples \u062b\u0644\u0627\u062b \u0627\u0637\u0641\u0627\u0644<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-397-field_17-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"17\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-397-field_18-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"18\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-397-field_18\">Baby 1 First Name ( English \u0627\u0646\u062c\u0644\u064a\u0632\u064a) \u0627\u0633\u0645 \u0627\u0644\u0637\u0641\u0644  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-397-field_18\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][18]\" aria-errormessage=\"wpforms-397-field_18-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-397-field_20-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"20\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-397-field_20\">Baby 2 First Name ( English \u0627\u0646\u062c\u0644\u064a\u0632\u064a)  \u0627\u0633\u0645 \u0627\u0644\u0637\u0641\u0644 <\/label><input type=\"text\" id=\"wpforms-397-field_20\" class=\"wpforms-field-medium\" name=\"wpforms[fields][20]\" aria-errormessage=\"wpforms-397-field_20-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-397-field_22-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"22\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-397-field_22\">Baby 3 First Name ( English \u0627\u0646\u062c\u0644\u064a\u0632\u064a)\u0627\u0633\u0645 \u0627\u0644\u0637\u0641\u0644 <\/label><input type=\"text\" id=\"wpforms-397-field_22\" class=\"wpforms-field-medium\" name=\"wpforms[fields][22]\" aria-errormessage=\"wpforms-397-field_22-error\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-397-field_19-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"19\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-397-field_19\">Baby 1 First Name ( Arabic \u0639\u0631\u0628\u064a) \u0627\u0633\u0645 \u0627\u0644\u0637\u0641\u0644  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-397-field_19\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][19]\" aria-errormessage=\"wpforms-397-field_19-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-397-field_21-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"21\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-397-field_21\">Baby 2 First Name ( Arabic \u0639\u0631\u0628\u064a) \u0627\u0633\u0645 \u0627\u0644\u0637\u0641\u0644 <\/label><input type=\"text\" id=\"wpforms-397-field_21\" class=\"wpforms-field-medium\" name=\"wpforms[fields][21]\" aria-errormessage=\"wpforms-397-field_21-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-397-field_23-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"23\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-397-field_23\">Baby 3 First Name ( Arabic \u0639\u0631\u0628\u064a) \u0627\u0633\u0645 \u0627\u0644\u0637\u0641\u0644 <\/label><input type=\"text\" id=\"wpforms-397-field_23\" class=\"wpforms-field-medium\" name=\"wpforms[fields][23]\" aria-errormessage=\"wpforms-397-field_23-error\" ><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-397-field_24-container\" class=\"wpforms-field wpforms-field-select wpforms-conditional-field wpforms-conditional-show wpforms-field-select-style-classic\" data-field-id=\"24\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-397-field_24\">Gender of the child \u062c\u0646\u0633 \u0627\u0644\u0645\u0648\u0644\u0648\u062f  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-397-field_24\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][24]\" required=\"required\"><option value=\"Male \u0630\u0643\u0631\" >Male \u0630\u0643\u0631<\/option><option value=\"Female \u0623\u0646\u062b\u0649\" >Female \u0623\u0646\u062b\u0649<\/option><\/select><\/div><div id=\"wpforms-397-field_25-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"25\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-397-field_25\">Birth Date \u062a\u0627\u0631\u064a\u062e \u0627\u0644\u0648\u0644\u0627\u062f\u0629 <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-397-field_25\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][25][date]\" aria-errormessage=\"wpforms-397-field_25-error\" required><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-397-field_26-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"26\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-397-field_26\">MRN of the child  \u0631\u0642\u0645 \u0645\u0644\u0641 \u0627\u0644\u0637\u0641\u0644 \u0627\u0644\u0637\u0628\u064a<\/label><input type=\"text\" id=\"wpforms-397-field_26\" class=\"wpforms-field-medium\" name=\"wpforms[fields][26]\" aria-errormessage=\"wpforms-397-field_26-error\" ><\/div><div id=\"wpforms-397-field_54-container\" class=\"wpforms-field wpforms-field-file-upload wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"54\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-397-field_54\">Attachments \u0627\u0644\u0645\u0631\u0641\u0642\u0627\u062a<\/label><div\n\t\tclass=\"wpforms-uploader\"\n\t\tdata-field-id=\"54\"\n\t\tdata-form-id=\"397\"\n\t\tdata-input-name=\"wpforms_397_54\"\n\t\tdata-extensions=\"jpg,jpeg,jpe,gif,png,bmp,tiff,tif,webp,avif,ico,heic,heif,heics,heifs,asf,asx,wmv,wmx,wm,avi,divx,mov,qt,mpeg,mpg,mpe,mp4,m4v,ogv,webm,mkv,3gp,3gpp,3g2,3gp2,txt,asc,c,cc,h,srt,csv,tsv,ics,rtx,css,vtt,mp3,m4a,m4b,aac,ra,ram,wav,x-wav,ogg,oga,flac,mid,midi,wma,wax,mka,rtf,pdf,class,tar,zip,gz,gzip,rar,7z,psd,xcf,doc,pot,pps,ppt,wri,xla,xls,xlt,xlw,mpp,docx,docm,dotx,dotm,xlsx,xlsm,xlsb,xltx,xltm,xlam,pptx,pptm,ppsx,ppsm,potx,potm,ppam,sldx,sldm,onetoc,onetoc2,onepkg,oxps,xps,odt,odp,ods,odg,odc,odb,odf,wp,wpd,key,numbers,pages,otf,ttf,woff,woff2\"\n\t\tdata-max-size=\"5242880\"\n\t\tdata-max-file-number=\"3\"\n\t\tdata-post-max-size=\"536870912\"\n\t\tdata-max-parallel-uploads=\"4\"\n\t\tdata-parallel-uploads=\"true\"\n\t\tdata-file-chunk-size=\"2097152\">\n\t<div class=\"dz-message\">\n\t\t<svg viewBox=\"0 0 1024 1024\" focusable=\"false\" data-icon=\"inbox\" width=\"50px\" height=\"50px\" fill=\"currentColor\" aria-hidden=\"true\">\n\t\t\t<path d=\"M885.2 446.3l-.2-.8-112.2-285.1c-5-16.1-19.9-27.2-36.8-27.2H281.2c-17 0-32.1 11.3-36.9 27.6L139.4 443l-.3.7-.2.8c-1.3 4.9-1.7 9.9-1 14.8-.1 1.6-.2 3.2-.2 4.8V830a60.9 60.9 0 0 0 60.8 60.8h627.2c33.5 0 60.8-27.3 60.9-60.8V464.1c0-1.3 0-2.6-.1-3.7.4-4.9 0-9.6-1.3-14.1zm-295.8-43l-.3 15.7c-.8 44.9-31.8 75.1-77.1 75.1-22.1 0-41.1-7.1-54.8-20.6S436 441.2 435.6 419l-.3-15.7H229.5L309 210h399.2l81.7 193.3H589.4zm-375 76.8h157.3c24.3 57.1 76 90.8 140.4 90.8 33.7 0 65-9.4 90.3-27.2 22.2-15.6 39.5-37.4 50.7-63.6h156.5V814H214.4V480.1z\"><\/path>\n\t\t<\/svg>\n\t\t<span class=\"modern-title\">Click or drag files to this area to upload.<\/span>\n\n\t\t\t\t\t<span class=\"modern-hint\">You can upload up to 3 files.<\/span>\n\t\t\t<\/div>\n<\/div>\n<input\n\t\ttype=\"text\"\n\t\tautocomplete=\"off\"\n\t\treadonly\n\t\tclass=\"dropzone-input\"\n\t\tstyle=\"position:absolute!important;clip:rect(0,0,0,0)!important;height:1px!important;width:1px!important;border:0!important;overflow:hidden!important;padding:0!important;margin:0!important;\"\n\t\tid=\"wpforms-397-field_54\"\n\t\tname=\"wpforms_397_54\" \t\tvalue=\"\">\n<\/div><div id=\"wpforms-397-field_27-container\" class=\"wpforms-field wpforms-field-divider wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"27\" style=\"display:none;\"><h3 id=\"wpforms-397-field_27\" aria-errormessage=\"wpforms-397-field_27-error\">Father\u2019s Information \u0645\u0639\u0644\u0648\u0645\u0627\u062a \u0627\u0644\u0623\u0628<\/h3><\/div><div id=\"wpforms-397-field_28-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"28\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-397-field_28\">Father (Full name) \u0627\u0633\u0645 \u0627\u0644\u0623\u0628 \u0627\u0644\u0631\u0628\u0627\u0639\u064a <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-397-field_28\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][28]\" aria-errormessage=\"wpforms-397-field_28-error\" required><\/div><div id=\"wpforms-397-field_29-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"29\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-397-field_29\">Nationality \u0627\u0644\u062c\u0646\u0633\u064a\u0629 <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-397-field_29\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][29]\" aria-errormessage=\"wpforms-397-field_29-error\" required><\/div><div id=\"wpforms-397-field_30-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"30\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-397-field_30\">ID number \/ borders \/ passport \u0631\u0642\u0645 \u0627\u0644\u0627\u0642\u0627\u0645\u0629 \u0627\u0644\u062d\u062f\u0648\u062f \u062c\u0648\u0627\u0632 \u0627\u0644\u0633\u0641\u0631 <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-397-field_30\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][30]\" aria-errormessage=\"wpforms-397-field_30-error\" required><\/div><div id=\"wpforms-397-field_31-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"31\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-397-field_31\">Version number \u0631\u0642\u0645 \u0627\u0644\u0646\u0633\u062e\u0629<\/label><input type=\"text\" id=\"wpforms-397-field_31\" class=\"wpforms-field-medium\" name=\"wpforms[fields][31]\" aria-errormessage=\"wpforms-397-field_31-error\" ><\/div><div id=\"wpforms-397-field_32-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"32\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-397-field_32\">Expiry Date \u062a\u0627\u0631\u064a\u062e \u0627\u0644\u0625\u0646\u062a\u0647\u0627\u0621<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-397-field_32\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][32][date]\" aria-errormessage=\"wpforms-397-field_32-error\" ><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-397-field_33-container\" class=\"wpforms-field wpforms-field-phone wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"33\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-397-field_33\">Mobile no \u0631\u0642\u0645 \u0627\u0644\u062c\u0648\u0627\u0644<\/label><input type=\"tel\" id=\"wpforms-397-field_33\" class=\"wpforms-field-medium wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][33]\" aria-label=\"Mobile no \u0631\u0642\u0645 \u0627\u0644\u062c\u0648\u0627\u0644\" aria-errormessage=\"wpforms-397-field_33-error\" ><\/div><div id=\"wpforms-397-field_34-container\" class=\"wpforms-field wpforms-field-divider wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"34\" style=\"display:none;\"><h3 id=\"wpforms-397-field_34\" aria-errormessage=\"wpforms-397-field_34-error\">Mother\u2019s Information \u0645\u0639\u0644\u0648\u0645\u0627\u062a \u0627\u0644\u0623\u0645 <\/h3><\/div><div id=\"wpforms-397-field_35-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"35\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-397-field_35\">Mother (Full name) \u0627\u0633\u0645 \u0627\u0644\u0623\u0645 \u0627\u0644\u0631\u0628\u0627\u0639\u064a <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-397-field_35\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][35]\" aria-errormessage=\"wpforms-397-field_35-error\" required><\/div><div id=\"wpforms-397-field_36-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"36\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-397-field_36\">Nationality \u0627\u0644\u062c\u0646\u0633\u064a\u0629 <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-397-field_36\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][36]\" aria-errormessage=\"wpforms-397-field_36-error\" required><\/div><div id=\"wpforms-397-field_37-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"37\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-397-field_37\">ID#\/ border# \/ passport# \u0631\u0642\u0645 \u0627\u0644\u0627\u0642\u0627\u0645\u0629 \u0627\u0644\u062d\u062f\u0648\u062f \u062c\u0648\u0627\u0632 \u0627\u0644\u0633\u0641\u0631 <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-397-field_37\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][37]\" aria-errormessage=\"wpforms-397-field_37-error\" required><\/div><div id=\"wpforms-397-field_38-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"38\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-397-field_38\">Version number \u0631\u0642\u0645 \u0627\u0644\u0646\u0633\u062e\u0629 <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-397-field_38\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][38]\" aria-errormessage=\"wpforms-397-field_38-error\" required><\/div><div id=\"wpforms-397-field_39-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"39\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Expiry Date \u062a\u0627\u0631\u064a\u062e \u0627\u0644\u0625\u0646\u062a\u0647\u0627\u0621 <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-date-type-datepicker\"><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-397-field_39\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][39][date]\" aria-errormessage=\"wpforms-397-field_39-error\" required><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><label for=\"wpforms-397-field_39\" class=\"wpforms-field-sublabel after\">Date<\/label><\/div><div class=\"wpforms-field-row-block\"><input type=\"text\" id=\"wpforms-397-field_39-time\" class=\"wpforms-field-date-time-time wpforms-timepicker wpforms-field-required\" data-time-format=\"g:i A\" data-step=\"30\" data-rule-time12h=\"true\" name=\"wpforms[fields][39][time]\" aria-errormessage=\"wpforms-397-field_39-time-error\" required><label for=\"wpforms-397-field_39-time\" class=\"wpforms-field-sublabel after\">Time<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-397-field_40-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"40\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-397-field_40\">Relation to the child \u0635\u0644\u0629 \u0642\u0631\u0627\u0628\u0629 \u0627\u0644\u0645\u0628\u0644\u063a \u0628\u0627\u0644\u0645\u0648\u0644\u0648\u062f <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-397-field_40\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][40]\" aria-errormessage=\"wpforms-397-field_40-error\" required><\/div><\/div><!-- .wpforms-field-container --><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"397\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/www.dsah.sa\/telemedicine\/wp-json\/wp\/v2\/pages\/435\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-397\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><img decoding=\"async\" loading=\"lazy\" src=\"https:\/\/www.dsah.sa\/telemedicine\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/div><\/form><\/div>  <!-- .wpforms-container --><\/div>\n<\/div>\n\n\n<div class=\"wp-block-image\">\n<figure class=\"aligncenter size-large is-resized\"><img data-recalc-dims=\"1\" decoding=\"async\" loading=\"lazy\" src=\"https:\/\/i0.wp.com\/www.dsah.sa\/telemedicine\/wp-content\/uploads\/2025\/12\/mrd-leave-48.webp?ssl=1\" alt=\"\" style=\"width:800px\"\/><\/figure>\n<\/div>\n\n\n<style>\nbody  {\n  background-image: url(\"https:\/\/www.dsah.sa\/telemedicine\/wp-content\/uploads\/2025\/12\/Website-Header-1.webp\");\n  background-color: #1111;\nheight: 500px; \/* You must set a specified height *\/\n  background-position: center; \/* Center the image *\/\n  background-repeat: no-repeat;\n  background-size: cover;\n}\n.pagelayer-header{\n    display: none;\n} \n\n.pagelayer-footer{\n    display: none;\n}\n<\/style>\n","protected":false},"excerpt":{"rendered":"<p>Note: The report will be sent E-Mail registered in the hospital \u0645\u0644\u0627\u062d\u0638\u0629: \u0633\u064a\u062a\u0645 \u0625\u0631\u0633\u0627\u0644 \u0627\u0644\u062a\u0642\u0631\u064a\u0631 \u0625\u0644\u0649 \u0627\u0644\u0628\u0631\u064a\u062f \u0627\u0644\u0627\u0644\u0643\u062a\u0631\u0648\u0646\u064a \u0627\u0644\u0645\u0633\u062c\u0644 \u0644\u062f\u064a\u0646\u0627 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