{"id":451209,"date":"2026-04-07T11:29:09","date_gmt":"2026-04-07T10:29:09","guid":{"rendered":"https:\/\/dronline.ie\/en\/?page_id=451209"},"modified":"2026-04-07T11:30:04","modified_gmt":"2026-04-07T10:30:04","slug":"pre-travel-health-questionnaire-2","status":"publish","type":"page","link":"https:\/\/dronline.ie\/en\/pre-travel-health-questionnaire-2\/","title":{"rendered":"Pre-Travel Health Questionnaire"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"451209\" class=\"elementor elementor-451209\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-d12bee0 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"d12bee0\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-3475e01\" data-id=\"3475e01\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-68c8876 elementor-widget elementor-widget-heading\" data-id=\"68c8876\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h1 class=\"elementor-heading-title elementor-size-default\">Pre-Travel Health Questionnaire<\/h1>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-03bcc43 elementor-widget elementor-widget-shortcode\" data-id=\"03bcc43\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\"><div class=\"wpforms-container wpforms-container-full\" id=\"wpforms-451205\"><form id=\"wpforms-form-451205\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"451205\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/en\/wp-json\/wp\/v2\/pages\/451209\" data-token=\"6295bdae15989ce3ccfb2f917a425297\" data-token-time=\"1786448385\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-field-container\"><div id=\"wpforms-451205-field_1-container\" class=\"wpforms-field wpforms-field-content\" data-field-type=\"content\" data-field-id=\"1\"><div id=\"wpforms-451205-field_1\" class=\"wpforms-field-large wpforms-field-row\"><h3>\u2708\ufe0f <strong>Welcome to Your Travel Health Questionnaire<\/strong><\/h3>\n<p>\ud83d\udcdd To help us plan the best recommendations for your consultation, it's essential that you complete this form with information about <strong>yourself<\/strong> and your <strong>trip<\/strong>.<\/p>\n<p>\u23f0 <strong>Please fill it out as early as possible<\/strong> to ensure we have enough time to prepare everything you need.<\/p>\n<p>Thank you for your cooperation! \ud83c\udf0d\ud83d\udc89<\/p>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-451205-field_8-container\" class=\"wpforms-field wpforms-field-content\" data-field-type=\"content\" data-field-id=\"8\"><div id=\"wpforms-451205-field_8\" class=\"wpforms-field-medium wpforms-field-row\"><h3>\ud83d\udc64 <strong>Personal Information<\/strong><\/h3>\n<p>Please provide your personal details below:<\/p>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-451205-field_2-container\" class=\"wpforms-field wpforms-field-name\" data-field-type=\"name\" data-field-id=\"2\"><label class=\"wpforms-field-label\">Name <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-451205-field_2\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][2][first]\" required><label for=\"wpforms-451205-field_2\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-451205-field_2-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][2][last]\" required><label for=\"wpforms-451205-field_2-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/div><div id=\"wpforms-451205-field_3-container\" class=\"wpforms-field wpforms-field-email\" data-field-type=\"email\" data-field-id=\"3\"><label class=\"wpforms-field-label\">Email <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"email\" id=\"wpforms-451205-field_3\" class=\"wpforms-field-required wpforms-field-email-primary\" name=\"wpforms[fields][3][primary]\" spellcheck=\"false\" required><label for=\"wpforms-451205-field_3\" class=\"wpforms-field-sublabel after\">Email<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"email\" id=\"wpforms-451205-field_3-secondary\" class=\"wpforms-field-email-secondary wpforms-field-required\" data-rule-confirm=\"#wpforms-451205-field_3\" name=\"wpforms[fields][3][secondary]\" spellcheck=\"false\" required><label for=\"wpforms-451205-field_3-secondary\" class=\"wpforms-field-sublabel after\">Confirm Email<\/label><\/div><\/div><\/div><div id=\"wpforms-451205-field_4-container\" class=\"wpforms-field wpforms-field-layout\" data-field-type=\"layout\" data-field-id=\"4\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-451205-field_5-container\" class=\"wpforms-field wpforms-field-phone\" data-field-type=\"phone\" data-field-id=\"5\"><label class=\"wpforms-field-label\" for=\"wpforms-451205-field_5\">Phone Number <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-451205-field_5\" class=\"wpforms-field-medium wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][5]\" aria-label=\"Phone Number\" required><\/div><div id=\"wpforms-451205-field_14-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-451205-field_14\">Country of Origin<\/label><input type=\"text\" id=\"wpforms-451205-field_14\" class=\"wpforms-field-medium\" name=\"wpforms[fields][14]\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-451205-field_13-container\" class=\"wpforms-field wpforms-field-number\" data-field-type=\"number\" data-field-id=\"13\"><label class=\"wpforms-field-label\" for=\"wpforms-451205-field_13\">Age <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"number\" id=\"wpforms-451205-field_13\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][13]\" step=\"any\" required><\/div><div id=\"wpforms-451205-field_16-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"16\"><label class=\"wpforms-field-label\" for=\"wpforms-451205-field_16\">Occupation<\/label><input type=\"text\" id=\"wpforms-451205-field_16\" class=\"wpforms-field-medium\" name=\"wpforms[fields][16]\" ><\/div><\/div><\/div><\/div><div id=\"wpforms-451205-field_17-container\" class=\"wpforms-field wpforms-field-content\" data-field-type=\"content\" data-field-id=\"17\"><div id=\"wpforms-451205-field_17\" class=\"wpforms-field-medium wpforms-field-row\"><h3>\ud83c\udf0d <strong>Travel Information<\/strong><\/h3>\n<p>Please provide the details of your trip:<\/p>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-451205-field_18-container\" class=\"wpforms-field wpforms-field-layout\" data-field-type=\"layout\" data-field-id=\"18\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-451205-field_19-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-type=\"date-time\" data-field-id=\"19\"><label class=\"wpforms-field-label\" for=\"wpforms-451205-field_19\">Departure Date:  <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-451205-field_19\" 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][19][date]\" required><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-451205-field_20-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"20\"><label class=\"wpforms-field-label\" for=\"wpforms-451205-field_20\">Duration of Trip (in days):  <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-451205-field_20\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][20]\" required><\/div><\/div><\/div><\/div><div id=\"wpforms-451205-field_21-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"21\"><label class=\"wpforms-field-label\" for=\"wpforms-451205-field_21\">Region(s) of Travel: <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-451205-field_21\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][21]\" required><\/div><div id=\"wpforms-451205-field_23-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-type=\"textarea\" data-field-id=\"23\"><label class=\"wpforms-field-label\" for=\"wpforms-451205-field_23\">Countries and Duration in Each:  <span class=\"wpforms-required-label\">*<\/span><\/label><textarea id=\"wpforms-451205-field_23\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][23]\" required><\/textarea><\/div><div id=\"wpforms-451205-field_24-container\" class=\"wpforms-field wpforms-field-select wpforms-conditional-trigger wpforms-field-select-style-classic\" data-field-type=\"select\" data-field-id=\"24\"><label class=\"wpforms-field-label\" for=\"wpforms-451205-field_24\">Type of Trip <span class=\"wpforms-required-label\">*<\/span><\/label><select id=\"wpforms-451205-field_24\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][24]\" required=\"required\"><option value=\"-\"  class=\"choice-10 depth-1\"  >-<\/option><option value=\"Resort stay\"  class=\"choice-1 depth-1\"  >Resort stay<\/option><option value=\"Standard hotel or apartment stay\"  class=\"choice-2 depth-1\"  >Standard hotel or apartment stay<\/option><option value=\"Backpacking\"  class=\"choice-3 depth-1\"  >Backpacking<\/option><option value=\"Staying with friends or relatives (local home)\"  class=\"choice-4 depth-1\"  >Staying with friends or relatives (local home)<\/option><option value=\"Rural or remote area travel\"  class=\"choice-5 depth-1\"  >Rural or remote area travel<\/option><option value=\"Long-term stay (over 1 month)\"  class=\"choice-6 depth-1\"  >Long-term stay (over 1 month)<\/option><option value=\"Organised group tour\"  class=\"choice-7 depth-1\"  >Organised group tour<\/option><option value=\"Cruise\"  class=\"choice-8 depth-1\"  >Cruise<\/option><option value=\"Other\"  class=\"choice-9 depth-1\"  >Other<\/option><\/select><\/div><div id=\"wpforms-451205-field_25-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"text\" data-field-id=\"25\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-451205-field_25\">Please Specify <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-451205-field_25\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][25]\" required><\/div><div id=\"wpforms-451205-field_27-container\" class=\"wpforms-field wpforms-field-content\" data-field-type=\"content\" data-field-id=\"27\"><div id=\"wpforms-451205-field_27\" class=\"wpforms-field-medium wpforms-field-row\"><h3>\ud83d\udc89 <strong>Vaccination Requirements<\/strong><\/h3>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-451205-field_28-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"28\"><label class=\"wpforms-field-label\" for=\"wpforms-451205-field_28\">Vaccines Required (if known):<\/label><input type=\"text\" id=\"wpforms-451205-field_28\" class=\"wpforms-field-large\" name=\"wpforms[fields][28]\" ><div class=\"wpforms-field-description\">separate with comma<\/div><\/div><div id=\"wpforms-451205-field_29-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"29\"><label class=\"wpforms-field-label\" for=\"wpforms-451205-field_29\">Optional Vaccines (if known): <\/label><input type=\"text\" id=\"wpforms-451205-field_29\" class=\"wpforms-field-large\" name=\"wpforms[fields][29]\" ><div class=\"wpforms-field-description\">separate with comma<\/div><\/div><div id=\"wpforms-451205-field_30-container\" class=\"wpforms-field wpforms-field-content\" data-field-type=\"content\" data-field-id=\"30\"><div id=\"wpforms-451205-field_30\" class=\"wpforms-field-medium wpforms-field-row\"><h3>\u2695\ufe0f <strong>Medical Background<\/strong><\/h3>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-451205-field_31-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline wpforms-conditional-trigger\" data-field-type=\"checkbox\" data-field-id=\"31\"><label class=\"wpforms-field-label\">What is your biological sex? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-451205-field_31\" class=\"wpforms-field-required\" data-choice-limit=\"1\"><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-451205-field_31_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][31][]\" value=\"Female\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-451205-field_31_2\">Female<\/label><\/li><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-451205-field_31_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][31][]\" value=\"Male\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-451205-field_31_1\">Male<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-451205-field_31_3\" data-rule-check-limit=\"true\" name=\"wpforms[fields][31][]\" value=\"Other\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-451205-field_31_3\">Other<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-451205-field_31_4\" data-rule-check-limit=\"true\" name=\"wpforms[fields][31][]\" value=\"Prefer not to say\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-451205-field_31_4\">Prefer not to say<\/label><\/li><\/ul><\/div><div id=\"wpforms-451205-field_32-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"checkbox\" data-field-id=\"32\" style=\"display:none;\"><label class=\"wpforms-field-label\">Are you pregnant or planning to become pregnant during your trip or within 3 months afterward? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-451205-field_32\" class=\"wpforms-field-required\" data-choice-limit=\"1\"><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-451205-field_32_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][32][]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-451205-field_32_2\">Yes<\/label><\/li><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-451205-field_32_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][32][]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-451205-field_32_1\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-451205-field_33-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"checkbox\" data-field-id=\"33\" style=\"display:none;\"><label class=\"wpforms-field-label\">Are you breastfeeding or planning to during your trip? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-451205-field_33\" class=\"wpforms-field-required\" data-choice-limit=\"1\"><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-451205-field_33_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][33][]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-451205-field_33_2\">Yes<\/label><\/li><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-451205-field_33_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][33][]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-451205-field_33_1\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-451205-field_34-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline wpforms-conditional-trigger\" data-field-type=\"checkbox\" data-field-id=\"34\"><label class=\"wpforms-field-label\">Have you recently had an infection (e.g., cold, flu, fever)? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-451205-field_34\" class=\"wpforms-field-required\" data-choice-limit=\"1\"><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-451205-field_34_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][34][]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-451205-field_34_2\">Yes<\/label><\/li><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-451205-field_34_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][34][]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-451205-field_34_1\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-451205-field_35-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"text\" data-field-id=\"35\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-451205-field_35\">Please, provide details: <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-451205-field_35\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][35]\" required><\/div><div id=\"wpforms-451205-field_36-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline wpforms-conditional-trigger\" data-field-type=\"checkbox\" data-field-id=\"36\"><label class=\"wpforms-field-label\">Do you have any allergies (e.g., eggs, antibiotics, nuts)? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-451205-field_36\" class=\"wpforms-field-required\" data-choice-limit=\"1\"><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-451205-field_36_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][36][]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-451205-field_36_2\">Yes<\/label><\/li><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-451205-field_36_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][36][]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-451205-field_36_1\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-451205-field_37-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"text\" data-field-id=\"37\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-451205-field_37\">Please, provide details: <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-451205-field_37\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][37]\" required><\/div><div id=\"wpforms-451205-field_38-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline wpforms-conditional-trigger\" data-field-type=\"checkbox\" data-field-id=\"38\"><label class=\"wpforms-field-label\">Have you ever had a serious reaction to a vaccine? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-451205-field_38\" class=\"wpforms-field-required\" data-choice-limit=\"1\"><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-451205-field_38_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][38][]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-451205-field_38_2\">Yes<\/label><\/li><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-451205-field_38_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][38][]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-451205-field_38_1\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-451205-field_40-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"text\" data-field-id=\"40\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-451205-field_40\">Please, provide details: <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-451205-field_40\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][40]\" required><\/div><div id=\"wpforms-451205-field_39-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-type=\"checkbox\" data-field-id=\"39\"><label class=\"wpforms-field-label\">Do injections make you feel faint? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-451205-field_39\" class=\"wpforms-field-required\" data-choice-limit=\"1\"><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-451205-field_39_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][39][]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-451205-field_39_2\">Yes<\/label><\/li><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-451205-field_39_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][39][]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-451205-field_39_1\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-451205-field_41-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-type=\"checkbox\" data-field-id=\"41\"><label class=\"wpforms-field-label\">Do you or close family members have epilepsy? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-451205-field_41\" class=\"wpforms-field-required\" data-choice-limit=\"1\"><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-451205-field_41_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][41][]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-451205-field_41_2\">Yes<\/label><\/li><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-451205-field_41_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][41][]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-451205-field_41_1\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-451205-field_42-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-type=\"checkbox\" data-field-id=\"42\"><label class=\"wpforms-field-label\">Do you have a history of mental illness (e.g., depression, anxiety)? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-451205-field_42\" class=\"wpforms-field-required\" data-choice-limit=\"1\"><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-451205-field_42_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][42][]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-451205-field_42_2\">Yes<\/label><\/li><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-451205-field_42_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][42][]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-451205-field_42_1\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-451205-field_43-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-type=\"checkbox\" data-field-id=\"43\"><label class=\"wpforms-field-label\">Have you recently undergone any of the following treatments? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-451205-field_43\" class=\"wpforms-field-required\" data-choice-limit=\"3\"><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-451205-field_43_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][43][]\" value=\"Radiotherapy\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-451205-field_43_2\">Radiotherapy<\/label><\/li><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-451205-field_43_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][43][]\" value=\"Chemotherapy\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-451205-field_43_1\">Chemotherapy<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-451205-field_43_5\" data-rule-check-limit=\"true\" name=\"wpforms[fields][43][]\" value=\"Steroids\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-451205-field_43_5\">Steroids<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-451205-field_43_6\" data-rule-check-limit=\"true\" name=\"wpforms[fields][43][]\" value=\"None\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-451205-field_43_6\">None<\/label><\/li><\/ul><\/div><div id=\"wpforms-451205-field_44-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline wpforms-conditional-trigger\" data-field-type=\"checkbox\" data-field-id=\"44\"><label class=\"wpforms-field-label\">Do you have travel insurance? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-451205-field_44\" class=\"wpforms-field-required\" data-choice-limit=\"1\"><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-451205-field_44_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][44][]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-451205-field_44_2\">Yes<\/label><\/li><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-451205-field_44_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][44][]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-451205-field_44_1\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-451205-field_45-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"checkbox\" data-field-id=\"45\" style=\"display:none;\"><label class=\"wpforms-field-label\">If you have a medical condition, have you informed your insurer? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-451205-field_45\" class=\"wpforms-field-required\" data-choice-limit=\"1\"><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-451205-field_45_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][45][]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-451205-field_45_2\">Yes<\/label><\/li><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-451205-field_45_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][45][]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-451205-field_45_1\">No<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-451205-field_45_5\" data-rule-check-limit=\"true\" name=\"wpforms[fields][45][]\" value=\"Not Applicable\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-451205-field_45_5\">Not Applicable<\/label><\/li><\/ul><\/div><div id=\"wpforms-451205-field_108-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-type=\"checkbox\" data-field-id=\"108\"><label class=\"wpforms-field-label\"> Are you requesting Malaria prevention tablets for your trip? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-451205-field_108\" class=\"wpforms-field-required\" data-choice-limit=\"1\"><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-451205-field_108_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][108][]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-451205-field_108_2\">Yes<\/label><\/li><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-451205-field_108_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][108][]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-451205-field_108_1\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-451205-field_50-container\" class=\"wpforms-field wpforms-field-content\" data-field-type=\"content\" data-field-id=\"50\"><div id=\"wpforms-451205-field_50\" class=\"wpforms-field-large wpforms-field-row\"><h3>\ud83d\udc89 <strong>Vaccination History<\/strong><\/h3>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-451205-field_107-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline wpforms-conditional-trigger\" data-field-type=\"checkbox\" data-field-id=\"107\"><label class=\"wpforms-field-label\">Have you been vaccinated before? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-451205-field_107\" class=\"wpforms-field-required\" data-choice-limit=\"1\"><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-451205-field_107_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][107][]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-451205-field_107_2\">Yes<\/label><\/li><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-451205-field_107_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][107][]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-451205-field_107_1\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-451205-field_92-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline wpforms-conditional-field wpforms-conditional-show wpforms-conditional-trigger\" data-field-type=\"checkbox\" data-field-id=\"92\" style=\"display:none;\"><label class=\"wpforms-field-label\">Have you ever received any of the following vaccinations?\u00a0 <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-451205-field_92\" class=\"wpforms-field-required\"><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-451205-field_92_2\" name=\"wpforms[fields][92][]\" value=\"Diptheria\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-451205-field_92_2\">Diptheria<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-451205-field_92_3\" name=\"wpforms[fields][92][]\" value=\"Hepatitis A\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-451205-field_92_3\">Hepatitis A<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-451205-field_92_9\" name=\"wpforms[fields][92][]\" value=\"Hepatitis B\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-451205-field_92_9\">Hepatitis B<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-451205-field_92_5\" name=\"wpforms[fields][92][]\" value=\"Influenza\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-451205-field_92_5\">Influenza<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-451205-field_92_6\" name=\"wpforms[fields][92][]\" value=\"Japanese B Encephalitis\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-451205-field_92_6\">Japanese B Encephalitis<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-451205-field_92_4\" name=\"wpforms[fields][92][]\" value=\"Meningitis\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-451205-field_92_4\">Meningitis<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-451205-field_92_7\" name=\"wpforms[fields][92][]\" value=\"Polio\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-451205-field_92_7\">Polio<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-451205-field_92_11\" name=\"wpforms[fields][92][]\" value=\"Rabies\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-451205-field_92_11\">Rabies<\/label><\/li><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-451205-field_92_1\" name=\"wpforms[fields][92][]\" value=\"Tetanus\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-451205-field_92_1\">Tetanus<\/label><\/li><li class=\"choice-12 depth-1\"><input type=\"checkbox\" id=\"wpforms-451205-field_92_12\" name=\"wpforms[fields][92][]\" value=\"Tick Borne Encephalitis\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-451205-field_92_12\">Tick Borne Encephalitis<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-451205-field_92_8\" name=\"wpforms[fields][92][]\" value=\"Typhoid\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-451205-field_92_8\">Typhoid<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-451205-field_92_10\" name=\"wpforms[fields][92][]\" value=\"Yellow Fever\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-451205-field_92_10\">Yellow Fever<\/label><\/li><li class=\"choice-14 depth-1\"><input type=\"checkbox\" id=\"wpforms-451205-field_92_14\" name=\"wpforms[fields][92][]\" value=\"Other\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-451205-field_92_14\">Other<\/label><\/li><\/ul><\/div><div id=\"wpforms-451205-field_51-container\" class=\"wpforms-field wpforms-field-layout\" data-field-type=\"layout\" data-field-id=\"51\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-451205-field_96-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"date-time\" data-field-id=\"96\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-451205-field_96\">Diphtheria \u2013 if yes, please provide the date.<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-451205-field_96\" 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][96][date]\" ><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-451205-field_103-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"date-time\" data-field-id=\"103\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-451205-field_103\">Hepatitis B \u2013 if yes, please provide the date.<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-451205-field_103\" 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][103][date]\" ><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-451205-field_98-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"date-time\" data-field-id=\"98\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-451205-field_98\">Meningitis \u2013 if yes, please provide the date.<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-451205-field_98\" 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][98][date]\" ><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-451205-field_105-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"date-time\" data-field-id=\"105\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-451205-field_105\">Rabies \u2013 if yes, please provide the date.<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-451205-field_105\" 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][105][date]\" ><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-451205-field_102-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"date-time\" data-field-id=\"102\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-451205-field_102\">Typhoid \u2013 if yes, please provide the date.<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-451205-field_102\" 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][102][date]\" ><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-451205-field_100-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"date-time\" data-field-id=\"100\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-451205-field_100\">Japanese Encephalitis (Type B) \u2013 if yes, please provide the date.<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-451205-field_100\" 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][100][date]\" ><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-451205-field_97-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"date-time\" data-field-id=\"97\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-451205-field_97\">Hepatitis A \u2013 if yes, please provide the date.<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-451205-field_97\" 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][97][date]\" ><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-451205-field_99-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"date-time\" data-field-id=\"99\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-451205-field_99\">Influenza \u2013 if yes, please provide the date.<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-451205-field_99\" 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][99][date]\" ><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-451205-field_101-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"date-time\" data-field-id=\"101\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-451205-field_101\">Polio \u2013 if yes, please provide the date.<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-451205-field_101\" 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][101][date]\" ><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-451205-field_93-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"date-time\" data-field-id=\"93\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-451205-field_93\">Tetanus \u2013 if yes, please provide the date.<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-451205-field_93\" 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][93][date]\" ><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-451205-field_104-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"date-time\" data-field-id=\"104\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-451205-field_104\">Yellow Fever \u2013 if yes, please provide the date.<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-451205-field_104\" 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][104][date]\" ><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-451205-field_106-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"date-time\" data-field-id=\"106\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-451205-field_106\">Tick-Borne Encephalitis \u2013 if yes, please provide the date.<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-451205-field_106\" 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][106][date]\" ><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-451205-field_95-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"textarea\" data-field-id=\"95\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-451205-field_95\">What other vaccines have you been administered and when?<\/label><textarea id=\"wpforms-451205-field_95\" class=\"wpforms-field-medium\" name=\"wpforms[fields][95]\" ><\/textarea><\/div><div id=\"wpforms-451205-field_109-container\" class=\"wpforms-field wpforms-field-content\" data-field-type=\"content\" data-field-id=\"109\"><div id=\"wpforms-451205-field_109\" class=\"wpforms-field-large wpforms-field-row\"><h3>\ud83d\udd12RGPD<\/h3>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-451205-field_110-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-type=\"checkbox\" data-field-id=\"110\"><label class=\"wpforms-field-label\">Checkboxes <span class=\"wpforms-required-label\">*<\/span><\/label><ul 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class=\"wpforms-field-large wpforms-field-row\"><p>\ud83d\ude4f <strong>Thank you for your cooperation.<\/strong><\/p>\n<p>Wishing you a great consultation!<\/p>\n<p>\ud83d\udcbb <strong>Dr.Online<\/strong><\/p>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><\/div><!-- .wpforms-field-container --><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"451205\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/dronline.ie\/en\/wp-json\/wp\/v2\/pages\/451209\"><input type=\"hidden\" name=\"url_referer\" value=\"\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-451205\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><img decoding=\"async\" src=\"https:\/\/dronline.ie\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" 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