{"id":1266,"date":"2026-08-04T09:46:58","date_gmt":"2026-08-04T09:46:58","guid":{"rendered":"https:\/\/wp-stg.ibnsina-pharma.com\/?page_id=1266"},"modified":"2026-08-04T09:46:58","modified_gmt":"2026-08-04T09:46:58","slug":"test-form","status":"publish","type":"page","link":"https:\/\/ibnsina-pharma.com\/ar\/test-form\/","title":{"rendered":"test form"},"content":{"rendered":"<div class=\"wpcf7 no-js\" id=\"wpcf7-f1265-o1\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"1265\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/ar\/wp-json\/wp\/v2\/pages\/1266#wpcf7-f1265-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" enctype=\"multipart\/form-data\" novalidate=\"novalidate\" data-status=\"init\" data-trp-original-action=\"\/ar\/wp-json\/wp\/v2\/pages\/1266#wpcf7-f1265-o1\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"1265\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.7\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f1265-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/><input type=\"hidden\" name=\"_wpcf7dtx_version\" value=\"5.0.7\" \/>\n<\/fieldset>\n<div dir=\"rtl\">\n\t<h3>\u0646\u0645\u0648\u0630\u062c \u0627\u0644\u0625\u0628\u0644\u0627\u063a \u0639\u0646 \u0627\u0644\u0622\u062b\u0627\u0631 \u0627\u0644\u062c\u0627\u0646\u0628\u064a\u0629 \u0644\u0644\u0623\u062f\u0648\u064a\u0629\n\t<\/h3>\n\t<h4>1- \u0627\u0644\u0622\u062b\u0627\u0631 \u0627\u0644\u062c\u0627\u0646\u0628\u064a\u0629 \/ \u0627\u0644\u0623\u0639\u0631\u0627\u0636 \u0627\u0644\u0639\u0643\u0633\u064a\u0629\n\t<\/h4>\n\t<p><label>\u0645\u0627 \u0647\u0648 \u0646\u0648\u0639 \u0627\u0644\u0645\u0634\u0643\u0644\u0629 \u0627\u0644\u062a\u064a \u0648\u0627\u062c\u0647\u062a\u0647\u0627\u061f<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-297\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"checkbox-297[]\" value=\"Option 1\" \/><span class=\"wpcf7-list-item-label\">Option 1<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-297[]\" value=\"Option 2\" \/><span class=\"wpcf7-list-item-label\">Option 2<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"checkbox-297[]\" value=\"Option 3\" \/><span class=\"wpcf7-list-item-label\">Option 3<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"problem-type\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"problem-type[]\" value=\"\u062d\u062f\u062b \u0636\u0631\u0631 \u0623\u0648 \u0623\u062b\u0631 \u062c\u0627\u0646\u0628\u064a \u0633\u064a\u0626 \u0628\u0645\u0627 \u0641\u064a \u0630\u0644\u0643 \u0623\u0639\u0631\u0627\u0636 \u062c\u062f\u064a\u062f\u0629 \u0623\u0648 \u062a\u0641\u0627\u0642\u0645 \u0623\u0639\u0631\u0627\u0636 \u0633\u0627\u0628\u0642\u0629.\" \/><span class=\"wpcf7-list-item-label\">\u062d\u062f\u062b \u0636\u0631\u0631 \u0623\u0648 \u0623\u062b\u0631 \u062c\u0627\u0646\u0628\u064a \u0633\u064a\u0626 \u0628\u0645\u0627 \u0641\u064a \u0630\u0644\u0643 \u0623\u0639\u0631\u0627\u0636 \u062c\u062f\u064a\u062f\u0629 \u0623\u0648 \u062a\u0641\u0627\u0642\u0645 \u0623\u0639\u0631\u0627\u0636 \u0633\u0627\u0628\u0642\u0629.<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"problem-type[]\" value=\"\u062a\u0645 \u0627\u0633\u062a\u062e\u062f\u0627\u0645 \u0627\u0644\u0645\u0646\u062a\u062c \u0628\u0634\u0643\u0644 \u062e\u0627\u0637\u0626 \u0645\u0645\u0627 \u0623\u062f\u0649 \u0623\u0648 \u0643\u0627\u062f \u0623\u0646 \u064a\u0624\u062f\u064a \u0625\u0644\u0649 \u0645\u0634\u0643\u0644\u0629.\" \/><span class=\"wpcf7-list-item-label\">\u062a\u0645 \u0627\u0633\u062a\u062e\u062f\u0627\u0645 \u0627\u0644\u0645\u0646\u062a\u062c \u0628\u0634\u0643\u0644 \u062e\u0627\u0637\u0626 \u0645\u0645\u0627 \u0623\u062f\u0649 \u0623\u0648 \u0643\u0627\u062f \u0623\u0646 \u064a\u0624\u062f\u064a \u0625\u0644\u0649 \u0645\u0634\u0643\u0644\u0629.<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"problem-type[]\" value=\"\u0644\u0648\u062d\u0638\u062a \u0645\u0634\u0643\u0644\u0629 \u0641\u064a \u062c\u0648\u062f\u0629 \u0627\u0644\u0645\u0646\u062a\u062c.\" \/><span class=\"wpcf7-list-item-label\">\u0644\u0648\u062d\u0638\u062a \u0645\u0634\u0643\u0644\u0629 \u0641\u064a \u062c\u0648\u062f\u0629 \u0627\u0644\u0645\u0646\u062a\u062c.<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"problem-type[]\" value=\"\u062d\u062f\u062b\u062a \u0645\u0634\u0627\u0643\u0644 \u0628\u0639\u062f \u0627\u0644\u062a\u063a\u064a\u064a\u0631 \u0645\u0646 \u0645\u0646\u062a\u062c \u0634\u0631\u0643\u0629 \u0645\u0635\u0646\u0639\u0629 \u0625\u0644\u0649 \u0634\u0631\u0643\u0629 \u0623\u062e\u0631\u0649.\" \/><span class=\"wpcf7-list-item-label\">\u062d\u062f\u062b\u062a \u0645\u0634\u0627\u0643\u0644 \u0628\u0639\u062f \u0627\u0644\u062a\u063a\u064a\u064a\u0631 \u0645\u0646 \u0645\u0646\u062a\u062c \u0634\u0631\u0643\u0629 \u0645\u0635\u0646\u0639\u0629 \u0625\u0644\u0649 \u0634\u0631\u0643\u0629 \u0623\u062e\u0631\u0649.<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label>\u0647\u0644 \u062d\u062f\u062b \u0623\u064a \u0645\u0645\u0627 \u064a\u0644\u064a\u061f<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"serious-event\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"serious-event[]\" value=\"\u062f\u062e\u0648\u0644 \u0627\u0644\u0645\u0633\u062a\u0634\u0641\u0649 (\u0627\u0644\u062a\u0646\u0648\u064a\u0645) \u0623\u0648 \u062a\u0645\u062f\u064a\u062f \u0641\u062a\u0631\u0629 \u0627\u0644\u0625\u0642\u0627\u0645\u0629.\" \/><span class=\"wpcf7-list-item-label\">\u062f\u062e\u0648\u0644 \u0627\u0644\u0645\u0633\u062a\u0634\u0641\u0649 (\u0627\u0644\u062a\u0646\u0648\u064a\u0645) \u0623\u0648 \u062a\u0645\u062f\u064a\u062f \u0641\u062a\u0631\u0629 \u0627\u0644\u0625\u0642\u0627\u0645\u0629.<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"serious-event[]\" value=\"\u062a\u0637\u0644\u0628 \u0627\u0644\u062a\u062f\u062e\u0644 \u0644\u0645\u0646\u0639 \u0636\u0631\u0631 \u062f\u0627\u0626\u0645.\" \/><span class=\"wpcf7-list-item-label\">\u062a\u0637\u0644\u0628 \u0627\u0644\u062a\u062f\u062e\u0644 \u0644\u0645\u0646\u0639 \u0636\u0631\u0631 \u062f\u0627\u0626\u0645.<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"serious-event[]\" value=\"\u0625\u0639\u0627\u0642\u0629 \u0623\u0648 \u0645\u0634\u0643\u0644\u0629 \u0635\u062d\u064a\u0629.\" \/><span class=\"wpcf7-list-item-label\">\u0625\u0639\u0627\u0642\u0629 \u0623\u0648 \u0645\u0634\u0643\u0644\u0629 \u0635\u062d\u064a\u0629.<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"serious-event[]\" value=\"\u0639\u064a\u0628 \u062e\u0644\u0642\u064a \u0644\u0644\u0645\u0648\u0627\u0644\u064a\u062f.\" \/><span class=\"wpcf7-list-item-label\">\u0639\u064a\u0628 \u062e\u0644\u0642\u064a \u0644\u0644\u0645\u0648\u0627\u0644\u064a\u062f.<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"serious-event[]\" value=\"\u0627\u0646\u062a\u0642\u0627\u0644 \u0639\u062f\u0648\u0649 \u0639\u0646 \u0637\u0631\u064a\u0642 \u0627\u0644\u062f\u0648\u0627\u0621 \u0623\u0648 \u0627\u0644\u062c\u0647\u0627\u0632 \u0627\u0644\u0637\u0628\u064a.\" \/><span class=\"wpcf7-list-item-label\">\u0627\u0646\u062a\u0642\u0627\u0644 \u0639\u062f\u0648\u0649 \u0639\u0646 \u0637\u0631\u064a\u0642 \u0627\u0644\u062f\u0648\u0627\u0621 \u0623\u0648 \u0627\u0644\u062c\u0647\u0627\u0632 \u0627\u0644\u0637\u0628\u064a.<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"serious-event[]\" value=\"\u062e\u0637\u0631 \u0639\u0644\u0649 \u0627\u0644\u062d\u064a\u0627\u0629.\" \/><span class=\"wpcf7-list-item-label\">\u062e\u0637\u0631 \u0639\u0644\u0649 \u0627\u0644\u062d\u064a\u0627\u0629.<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"serious-event[]\" value=\"\u0648\u0641\u0627\u0629.\" \/><span class=\"wpcf7-list-item-label\">\u0648\u0641\u0627\u0629.<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"serious-event[]\" value=\"\u062d\u062f\u062b \u0637\u0628\u064a \u0647\u0627\u0645 \u062e\u0637\u064a\u0631 \u0622\u062e\u0631.\" \/><span class=\"wpcf7-list-item-label\">\u062d\u062f\u062b \u0637\u0628\u064a \u0647\u0627\u0645 \u062e\u0637\u064a\u0631 \u0622\u062e\u0631.<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label>\u062a\u0627\u0631\u064a\u062e \u0627\u0644\u0648\u0641\u0627\u0629 (\u0641\u064a \u062d\u0627\u0644 \u062d\u062f\u0648\u062b \u0648\u0641\u0627\u0629)<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"death-date\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"death-date\" \/><\/span><\/label>\n\t<\/p>\n\t<p><label>\u062a\u0627\u0631\u064a\u062e \u0648\u0642\u0648\u0639 \u0627\u0644\u0645\u0634\u0643\u0644\u0629<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"problem-date\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"problem-date\" \/><\/span><\/label>\n\t<\/p>\n\t<p><label>\u0623\u062e\u0628\u0631\u0646\u0627 \u0628\u0645\u0627 \u062d\u062f\u062b \u0648\u0643\u064a\u0641 \u062d\u062f\u062b (\u064a\u0631\u062c\u0649 \u0630\u0643\u0631 \u0623\u0643\u0628\u0631 \u0642\u062f\u0631 \u0645\u0645\u0643\u0646 \u0645\u0646 \u0627\u0644\u062a\u0641\u0627\u0635\u064a\u0644)<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"problem-details\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"problem-details\"><\/textarea><\/span><\/label>\n\t<\/p>\n\t<h4>\u0627\u0644\u0627\u062e\u062a\u0628\u0627\u0631\u0627\u062a \u0630\u0627\u062a \u0627\u0644\u0635\u0644\u0629 \/ \u0627\u0644\u0628\u064a\u0627\u0646\u0627\u062a \u0627\u0644\u0645\u062e\u0628\u0631\u064a\u0629\n\t<\/h4>\n\t<p><label>\u062a\u0627\u0631\u064a\u062e \u0627\u0644\u0627\u062e\u062a\u0628\u0627\u0631<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"test-date\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"test-date\" \/><\/span><\/label>\n\t<\/p>\n\t<p><label>\u0627\u0633\u0645 \u0627\u0644\u0627\u062e\u062a\u0628\u0627\u0631<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"test-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"test-name\" \/><\/span><\/label>\n\t<\/p>\n\t<p><label>\u0646\u062a\u064a\u062c\u0629 \u0627\u0644\u0627\u062e\u062a\u0628\u0627\u0631<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"test-result\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"test-result\" \/><\/span><\/label>\n\t<\/p>\n\t<p><label>\u0627\u0644\u062d\u062f \u0627\u0644\u0623\u062f\u0646\u0649 \u0644\u0644\u0645\u0639\u062f\u0644 \u0627\u0644\u0637\u0628\u064a\u0639\u064a<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"normal-range-min\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"normal-range-min\" \/><\/span><\/label>\n\t<\/p>\n\t<p><label>\u0627\u0644\u062d\u062f \u0627\u0644\u0623\u0642\u0635\u0649 \u0644\u0644\u0645\u0639\u062f\u0644 \u0627\u0644\u0637\u0628\u064a\u0639\u064a<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"normal-range-max\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"normal-range-max\" \/><\/span><\/label>\n\t<\/p>\n\t<p><label>\u0625\u0636\u0627\u0641\u0629 \u0627\u062e\u062a\u0628\u0627\u0631 \u0622\u062e\u0631<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"additional-test\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"additional-test\" \/><\/span><\/label>\n\t<\/p>\n\t<p><label>\u0645\u0644\u0627\u062d\u0638\u0627\u062a \u0625\u0636\u0627\u0641\u064a\u0629<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"additional-test-notes\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"additional-test-notes\"><\/textarea><\/span><\/label>\n\t<\/p>\n\t<p><label>\u0647\u0644 \u0644\u0627 \u064a\u0632\u0627\u0644 \u0627\u0644\u0645\u0646\u062a\u062c \u0628\u062d\u0648\u0632\u062a\u0643 \u0641\u064a \u062d\u0627\u0644 \u0627\u062d\u062a\u062c\u0646\u0627 \u0644\u062a\u0642\u064a\u064a\u0645\u0647\u061f<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"product-in-possession\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"product-in-possession\" value=\"\u0646\u0639\u0645\" \/><span class=\"wpcf7-list-item-label\">\u0646\u0639\u0645<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"product-in-possession\" value=\"\u0644\u0627\" \/><span class=\"wpcf7-list-item-label\">\u0644\u0627<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label>\u0647\u0644 \u0644\u062f\u064a\u0643 \u0635\u0648\u0631\u0629 \u0644\u0644\u0645\u0646\u062a\u062c\u061f<\/label>\n\t<\/p>\n\t<p>\u0639\u0644\u0649 \u0627\u0644\u0631\u063a\u0645 \u0645\u0646 \u0623\u0646\u0647\u0627 \u0644\u064a\u0633\u062a \u0625\u0644\u0632\u0627\u0645\u064a\u0629\u060c \u0625\u0644\u0627 \u0623\u0646 \u0635\u0648\u0631 \u062c\u0645\u064a\u0639 \u062c\u0648\u0627\u0646\u0628 \u0627\u0644\u0645\u0646\u062a\u062c \u0633\u062a\u0633\u0627\u0639\u062f \u0641\u064a \u0645\u0631\u0627\u062c\u0639\u0629 \u062a\u0642\u0631\u064a\u0631\u0643.\n\t<\/p>\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"product-photo\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"product-photo\" value=\"\u0646\u0639\u0645\" \/><span class=\"wpcf7-list-item-label\">\u0646\u0639\u0645<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"product-photo\" value=\"\u0644\u0627\" \/><span class=\"wpcf7-list-item-label\">\u0644\u0627<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label>\u0625\u0630\u0627 \u0643\u0627\u0646\u062a \u0627\u0644\u0625\u062c\u0627\u0628\u0629 \u0628\u0646\u0639\u0645\u060c \u064a\u0631\u062c\u0649 \u062a\u062d\u0645\u064a\u0644 \u0627\u0644\u0645\u0644\u0641\u0627\u062a \u0630\u0627\u062a \u0627\u0644\u0635\u0644\u0629<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"product-files\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file\" accept=\".jpg,.jpeg,.png,.pdf,.doc,.docx\" aria-invalid=\"false\" type=\"file\" name=\"product-files\" \/><\/span><\/label>\n\t<\/p>\n\t<h4>2- \u0627\u0644\u0645\u0646\u062a\u062c \u0627\u0644\u0637\u0628\u064a\n\t<\/h4>\n\t<h5>\u0628\u064a\u0627\u0646\u0627\u062a \u0627\u0644\u0645\u0646\u062a\u062c\n\t<\/h5>\n\t<p><label>\u0627\u0633\u0645 \u0627\u0644\u0645\u0646\u062a\u062c<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"product-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"product-name\" \/><\/span><\/label>\n\t<\/p>\n\t<p><label>\u0627\u0644\u062c\u0631\u0639\u0629<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"product-dose\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"product-dose\" \/><\/span><\/label>\n\t<\/p>\n\t<p><label>\u0627\u0644\u0634\u0643\u0644 \u0627\u0644\u0635\u064a\u062f\u0644\u0627\u0646\u064a<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"pharmaceutical-form\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"pharmaceutical-form\" \/><\/span><\/label>\n\t<\/p>\n\t<p><label>\u0637\u0631\u064a\u0642\u0629 \u0627\u0644\u0627\u0633\u062a\u062e\u062f\u0627\u0645<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"administration-route\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"administration-route\" \/><\/span><\/label>\n\t<\/p>\n\t<p><label>\u0627\u0633\u0645 \u0627\u0644\u0634\u0631\u0643\u0629 \u0627\u0644\u0645\u0635\u0646\u0639\u0629 \u0644\u0644\u0645\u0646\u062a\u062c<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"manufacturer-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"manufacturer-name\" \/><\/span><\/label>\n\t<\/p>\n\t<p><label>\u062a\u0627\u0631\u064a\u062e \u0627\u0644\u062a\u0635\u0646\u064a\u0639<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"manufacturing-date\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"manufacturing-date\" \/><\/span><\/label>\n\t<\/p>\n\t<p><label>\u062a\u0627\u0631\u064a\u062e \u0627\u0644\u0627\u0646\u062a\u0647\u0627\u0621<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"expiry-date\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"expiry-date\" \/><\/span><\/label>\n\t<\/p>\n\t<p><label>\u0631\u0642\u0645 \u0627\u0644\u062a\u0634\u063a\u064a\u0644\u0629 (Batch number)<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"batch-number\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"batch-number\" \/><\/span><\/label>\n\t<\/p>\n\t<p><label>\u0647\u0644 \u0627\u0644\u0639\u0644\u0627\u062c \/ \u0627\u0644\u0627\u0633\u062a\u062e\u062f\u0627\u0645 \u0644\u0627 \u064a\u0632\u0627\u0644 \u0645\u0633\u062a\u0645\u0631\u064b\u0627\u061f<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"treatment-ongoing\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"treatment-ongoing\" value=\"\u0646\u0639\u0645\" \/><span class=\"wpcf7-list-item-label\">\u0646\u0639\u0645<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"treatment-ongoing\" value=\"\u0644\u0627\" \/><span class=\"wpcf7-list-item-label\">\u0644\u0627<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n\t<h5>\u0645\u0639\u0644\u0648\u0645\u0627\u062a \u0639\u0646 \u0645\u0646\u062a\u062c \u0622\u062e\u0631\n\t<\/h5>\n\t<p><label>\u0627\u0633\u0645 \u0627\u0644\u0645\u0646\u062a\u062c<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"other-product-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"other-product-name\" \/><\/span><\/label>\n\t<\/p>\n\t<p><label>\u0627\u0644\u062c\u0631\u0639\u0629<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"other-product-dose\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"other-product-dose\" \/><\/span><\/label>\n\t<\/p>\n\t<p><label>\u0627\u0644\u0634\u0643\u0644 \u0627\u0644\u0635\u064a\u062f\u0644\u0627\u0646\u064a<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"other-pharmaceutical-form\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"other-pharmaceutical-form\" \/><\/span><\/label>\n\t<\/p>\n\t<p><label>\u0637\u0631\u064a\u0642\u0629 \u0627\u0644\u0627\u0633\u062a\u062e\u062f\u0627\u0645<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"other-administration-route\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"other-administration-route\" \/><\/span><\/label>\n\t<\/p>\n\t<p><label>\u0627\u0633\u0645 \u0627\u0644\u0634\u0631\u0643\u0629 \u0627\u0644\u0645\u0635\u0646\u0639\u0629<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"other-manufacturer-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"other-manufacturer-name\" \/><\/span><\/label>\n\t<\/p>\n\t<p><label>\u0647\u0644 \u0627\u0644\u0639\u0644\u0627\u062c \u0644\u0627 \u064a\u0632\u0627\u0644 \u0645\u0633\u062a\u0645\u0631\u064b\u0627\u061f<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"other-treatment-ongoing\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"other-treatment-ongoing\" value=\"\u0646\u0639\u0645\" \/><span class=\"wpcf7-list-item-label\">\u0646\u0639\u0645<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"other-treatment-ongoing\" value=\"\u0644\u0627\" \/><span class=\"wpcf7-list-item-label\">\u0644\u0627<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n\t<h5>\u0645\u0643\u0627\u0646 \u0648\u062a\u0627\u0631\u064a\u062e \u0627\u0644\u0634\u0631\u0627\u0621\n\t<\/h5>\n\t<p><label>\u0627\u0644\u0627\u0633\u0645 (\u0627\u0633\u0645 \u0627\u0644\u0635\u064a\u062f\u0644\u064a\u0629 \u0623\u0648 \u0627\u0644\u062c\u0647\u0629)<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"purchase-location-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"purchase-location-name\" \/><\/span><\/label>\n\t<\/p>\n\t<p><label>\u0627\u0644\u062f\u0648\u0644\u0629<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"purchase-country\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"purchase-country\" \/><\/span><\/label>\n\t<\/p>\n\t<p><label>\u0627\u0644\u0639\u0646\u0648\u0627\u0646<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"purchase-address\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"purchase-address\" \/><\/span><\/label>\n\t<\/p>\n\t<p><label>\u0627\u0644\u0645\u062f\u064a\u0646\u0629<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"purchase-city\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"purchase-city\" \/><\/span><\/label>\n\t<\/p>\n\t<p><label>\u0627\u0644\u0648\u0644\u0627\u064a\u0629 \/ \u0627\u0644\u0645\u062d\u0627\u0641\u0638\u0629<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"purchase-state\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"purchase-state\" \/><\/span><\/label>\n\t<\/p>\n\t<p><label>\u0627\u0644\u0631\u0645\u0632 \u0627\u0644\u0628\u0631\u064a\u062f\u064a<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"purchase-postal-code\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"purchase-postal-code\" \/><\/span><\/label>\n\t<\/p>\n\t<p><label>\u0627\u0644\u0645\u0648\u0642\u0639 \u0627\u0644\u0625\u0644\u0643\u062a\u0631\u0648\u0646\u064a \u0641\u064a \u062d\u0627\u0644 \u0627\u0644\u0634\u0631\u0627\u0621 \u0639\u0628\u0631 \u0627\u0644\u0625\u0646\u062a\u0631\u0646\u062a<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"purchase-website\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-url wpcf7-text wpcf7-validates-as-url\" aria-invalid=\"false\" value=\"\" type=\"url\" name=\"purchase-website\" \/><\/span><\/label>\n\t<\/p>\n\t<p><label>\u062a\u0627\u0631\u064a\u062e \u0627\u0644\u0634\u0631\u0627\u0621<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"purchase-date\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"purchase-date\" \/><\/span><\/label>\n\t<\/p>\n\t<h5>\u062a\u0648\u0627\u0631\u064a\u062e \u0627\u0644\u0627\u0633\u062a\u062e\u062f\u0627\u0645\n\t<\/h5>\n\t<p>\u0625\u0630\u0627 \u0643\u0627\u0646 \u0627\u0644\u062a\u0627\u0631\u064a\u062e \u063a\u064a\u0631 \u0645\u0639\u0631\u0648\u0641\u060c \u064a\u0631\u062c\u0649 \u0630\u0643\u0631 \u0627\u0644\u0645\u062f\u0629 \u0627\u0644\u062a\u0642\u0631\u064a\u0628\u064a\u0629 \u0628\u0627\u0644\u064a\u0648\u0645 \/ \u0627\u0644\u0634\u0647\u0631 \/ \u0627\u0644\u0633\u0646\u0629.\n\t<\/p>\n\t<p><label>\u062a\u0627\u0631\u064a\u062e \u0627\u0644\u0628\u062f\u0621 \u0641\u064a \u062a\u0646\u0627\u0648\u0644 \u0623\u0648 \u0627\u0633\u062a\u062e\u062f\u0627\u0645 \u0627\u0644\u0645\u0646\u062a\u062c<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"product-start-date\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"product-start-date\" \/><\/span><\/label>\n\t<\/p>\n\t<p><label>\u062a\u0627\u0631\u064a\u062e \u0627\u0644\u062a\u0648\u0642\u0641 \u0639\u0646 \u062a\u0646\u0627\u0648\u0644 \u0623\u0648 \u0627\u0633\u062a\u062e\u062f\u0627\u0645 \u0627\u0644\u0645\u0646\u062a\u062c<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"product-stop-date\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"product-stop-date\" \/><\/span><\/label>\n\t<\/p>\n\t<p><label>\u062a\u0627\u0631\u064a\u062e \u062a\u0642\u0644\u064a\u0644 \u062c\u0631\u0639\u0629 \u0627\u0644\u0645\u0646\u062a\u062c<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"dose-reduction-date\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"dose-reduction-date\" \/><\/span><\/label>\n\t<\/p>\n\t<p><label>\u0623\u0648\u060c \u0623\u0639\u0637 \u0623\u0641\u0636\u0644 \u062a\u0642\u062f\u064a\u0631 \u0644\u0644\u0645\u062f\u0629<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"estimated-duration\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"estimated-duration\" \/><\/span><\/label>\n\t<\/p>\n\t<p><label>\u0645\u0627 \u0647\u0648 \u0633\u0628\u0628 \u0627\u0633\u062a\u062e\u062f\u0627\u0645 \u0627\u0644\u0645\u0646\u062a\u062c\u061f (\u0645\u062b\u0644 \u0627\u0644\u062d\u0627\u0644\u0629 \u0627\u0644\u0645\u0631\u0636\u064a\u0629 \u0627\u0644\u062a\u064a \u0643\u0627\u0646 \u0645\u0646 \u0627\u0644\u0645\u0641\u062a\u0631\u0636 \u0639\u0644\u0627\u062c\u0647\u0627)<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"product-use-reason\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"product-use-reason\"><\/textarea><\/span><\/label>\n\t<\/p>\n\t<p><label>\u0647\u0644 \u062a\u0648\u0642\u0641\u062a \u0627\u0644\u0645\u0634\u0643\u0644\u0629 \u0628\u0639\u062f \u062a\u0642\u0644\u064a\u0644 \u0627\u0644\u062c\u0631\u0639\u0629 \u0623\u0648 \u0627\u0644\u062a\u0648\u0642\u0641 \u0639\u0646 \u0627\u0633\u062a\u062e\u062f\u0627\u0645 \u0627\u0644\u0645\u0646\u062a\u062c\u061f<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"problem-stopped\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"problem-stopped\" value=\"\u0646\u0639\u0645\" \/><span class=\"wpcf7-list-item-label\">\u0646\u0639\u0645<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"problem-stopped\" value=\"\u0644\u0627\" \/><span class=\"wpcf7-list-item-label\">\u0644\u0627<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label>\u0647\u0644 \u0639\u0627\u062f\u062a \u0627\u0644\u0645\u0634\u0643\u0644\u0629 \u0625\u0630\u0627 \u0628\u062f\u0623 \u0627\u0644\u0634\u062e\u0635 \u0641\u064a \u0627\u0633\u062a\u062e\u062f\u0627\u0645 \u0627\u0644\u0645\u0646\u062a\u062c \u0645\u0631\u0629 \u0623\u062e\u0631\u0649\u061f<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"problem-returned\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"problem-returned\" value=\"\u0646\u0639\u0645\" \/><span class=\"wpcf7-list-item-label\">\u0646\u0639\u0645<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"problem-returned\" value=\"\u0644\u0627\" \/><span class=\"wpcf7-list-item-label\">\u0644\u0627<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"problem-returned\" value=\"\u0644\u0645 \u064a\u062a\u0645 \u0625\u0639\u0627\u062f\u0629 \u0627\u0644\u0627\u0633\u062a\u062e\u062f\u0627\u0645\" \/><span class=\"wpcf7-list-item-label\">\u0644\u0645 \u064a\u062a\u0645 \u0625\u0639\u0627\u062f\u0629 \u0627\u0644\u0627\u0633\u062a\u062e\u062f\u0627\u0645<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n\t<h4>3- \u0628\u064a\u0627\u0646\u0627\u062a \u0627\u0644\u0645\u0631\u064a\u0636\n\t<\/h4>\n\t<p><label>\u0627\u0644\u0623\u062d\u0631\u0641 \u0627\u0644\u0623\u0648\u0644\u0649 \u0645\u0646 \u0627\u0633\u0645 \u0627\u0644\u0645\u0631\u064a\u0636 (Patient initials)<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"patient-initials\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"patient-initials\" \/><\/span><\/label>\n\t<\/p>\n\t<p><label>\u0627\u0644\u062c\u0646\u0633<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"patient-gender\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"patient-gender\" value=\"\u0630\u0643\u0631\" \/><span class=\"wpcf7-list-item-label\">\u0630\u0643\u0631<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"patient-gender\" value=\"\u0623\u0646\u062b\u0649\" \/><span class=\"wpcf7-list-item-label\">\u0623\u0646\u062b\u0649<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label>\u0627\u0644\u0639\u0645\u0631<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"patient-age\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number\" min=\"0\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"patient-age\" \/><\/span><\/label>\n\t<\/p>\n\t<p><label>\u0627\u0644\u0648\u0632\u0646<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"patient-weight\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number\" min=\"0\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"patient-weight\" \/><\/span><\/label>\n\t<\/p>\n\t<p><label>\u0627\u0644\u0639\u0631\u0642<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"patient-race\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"patient-race[]\" value=\"\u0623\u0645\u0631\u064a\u0643\u064a \u0647\u0646\u062f\u064a \u0623\u0648 \u0645\u0646 \u0633\u0643\u0627\u0646 \u0623\u0644\u0627\u0633\u0643\u0627 \u0627\u0644\u0623\u0635\u0644\u064a\u064a\u0646\" \/><span class=\"wpcf7-list-item-label\">\u0623\u0645\u0631\u064a\u0643\u064a \u0647\u0646\u062f\u064a \u0623\u0648 \u0645\u0646 \u0633\u0643\u0627\u0646 \u0623\u0644\u0627\u0633\u0643\u0627 \u0627\u0644\u0623\u0635\u0644\u064a\u064a\u0646<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"patient-race[]\" value=\"\u0622\u0633\u064a\u0648\u064a\" \/><span class=\"wpcf7-list-item-label\">\u0622\u0633\u064a\u0648\u064a<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"patient-race[]\" value=\"\u0623\u0633\u0648\u062f \u0623\u0648 \u0645\u0646 \u0623\u0635\u0648\u0644 \u0623\u0641\u0631\u064a\u0642\u064a\u0629\" \/><span class=\"wpcf7-list-item-label\">\u0623\u0633\u0648\u062f \u0623\u0648 \u0645\u0646 \u0623\u0635\u0648\u0644 \u0623\u0641\u0631\u064a\u0642\u064a\u0629<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"patient-race[]\" value=\"\u0644\u0627\u062a\u064a\u0646\u064a \u0623\u0648 \u0647\u0633\u0628\u0627\u0646\u064a\" \/><span class=\"wpcf7-list-item-label\">\u0644\u0627\u062a\u064a\u0646\u064a \u0623\u0648 \u0647\u0633\u0628\u0627\u0646\u064a<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"patient-race[]\" value=\"\u0645\u0646 \u0627\u0644\u0634\u0631\u0642 \u0627\u0644\u0623\u0648\u0633\u0637 \u0623\u0648 \u0634\u0645\u0627\u0644 \u0623\u0641\u0631\u064a\u0642\u064a\u0627\" \/><span class=\"wpcf7-list-item-label\">\u0645\u0646 \u0627\u0644\u0634\u0631\u0642 \u0627\u0644\u0623\u0648\u0633\u0637 \u0623\u0648 \u0634\u0645\u0627\u0644 \u0623\u0641\u0631\u064a\u0642\u064a\u0627<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"patient-race[]\" value=\"\u0645\u0646 \u0633\u0643\u0627\u0646 \u0647\u0627\u0648\u0627\u064a \u0627\u0644\u0623\u0635\u0644\u064a\u064a\u0646 \u0623\u0648 \u062c\u0632\u0631 \u0627\u0644\u0645\u062d\u064a\u0637 \u0627\u0644\u0647\u0627\u062f\u0626\" \/><span class=\"wpcf7-list-item-label\">\u0645\u0646 \u0633\u0643\u0627\u0646 \u0647\u0627\u0648\u0627\u064a \u0627\u0644\u0623\u0635\u0644\u064a\u064a\u0646 \u0623\u0648 \u062c\u0632\u0631 \u0627\u0644\u0645\u062d\u064a\u0637 \u0627\u0644\u0647\u0627\u062f\u0626<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"patient-race[]\" value=\"\u0623\u0628\u064a\u0636\" \/><span class=\"wpcf7-list-item-label\">\u0623\u0628\u064a\u0636<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label>\u0642\u0627\u0626\u0645\u0629 \u0627\u0644\u062d\u0627\u0644\u0627\u062a \u0627\u0644\u0637\u0628\u064a\u0629 \u0627\u0644\u0645\u0639\u0631\u0648\u0641\u0629 (\u0645\u062b\u0644 \u0627\u0644\u0633\u0643\u0631\u064a\u060c \u0636\u063a\u0637 \u0627\u0644\u062f\u0645 \u0627\u0644\u0645\u0631\u062a\u0641\u0639\u060c \u0627\u0644\u0633\u0631\u0637\u0627\u0646\u060c \u0623\u0645\u0631\u0627\u0636 \u0627\u0644\u0642\u0644\u0628\u060c \u0623\u0648 \u063a\u064a\u0631\u0647\u0627)<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"medical-conditions\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"medical-conditions\"><\/textarea><\/span><\/label>\n\t<\/p>\n\t<p><label>\u064a\u0631\u062c\u0649 \u0630\u0643\u0631 \u062c\u0645\u064a\u0639 \u0623\u0646\u0648\u0627\u0639 \u0627\u0644\u062d\u0633\u0627\u0633\u064a\u0629 (\u0645\u062b\u0644 \u0627\u0644\u062d\u0633\u0627\u0633\u064a\u0629 \u0645\u0646 \u0623\u062f\u0648\u064a\u0629 \u0645\u0639\u064a\u0646\u0629\u060c \u0623\u0637\u0639\u0645\u0629\u060c \u062d\u0628\u0648\u0628 \u0627\u0644\u0644\u0642\u0627\u062d\u060c \u0623\u0648 \u063a\u064a\u0631\u0647\u0627)<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"allergies\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"allergies\"><\/textarea><\/span><\/label>\n\t<\/p>\n\t<p><label>\u0630\u0643\u0631 \u0623\u064a \u0645\u0639\u0644\u0648\u0645\u0627\u062a \u0647\u0627\u0645\u0629 \u0623\u062e\u0631\u0649 \u0639\u0646 \u0627\u0644\u0645\u0631\u064a\u0636 (\u0645\u062b\u0644 \u0627\u0644\u062a\u062f\u062e\u064a\u0646\u060c \u0627\u0644\u062d\u0645\u0644\u060c \u062a\u0639\u0627\u0637\u064a \u0627\u0644\u0643\u062d\u0648\u0644\u060c \u0625\u0644\u062e)<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"other-patient-information\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"other-patient-information\"><\/textarea><\/span><\/label>\n\t<\/p>\n\t<p><label>\u0642\u0627\u0626\u0645\u0629 \u0628\u062c\u0645\u064a\u0639 \u0627\u0644\u0623\u062f\u0648\u064a\u0629 \u0648\u0627\u0644\u0623\u062c\u0647\u0632\u0629 \u0627\u0644\u0637\u0628\u064a\u0629 \u0627\u0644\u062d\u0627\u0644\u064a\u0629 \u0627\u0644\u062a\u064a \u062a\u0633\u062a\u0644\u0632\u0645 \u0648\u0635\u0641\u0629 \u0637\u0628\u064a\u0629<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"prescription-medications\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"prescription-medications\"><\/textarea><\/span><\/label>\n\t<\/p>\n\t<p><label>\u0642\u0627\u0626\u0645\u0629 \u0628\u062c\u0645\u064a\u0639 \u0627\u0644\u0623\u062f\u0648\u064a\u0629 \u0627\u0644\u062a\u064a \u062a\u0635\u0631\u0641 \u0628\u062f\u0648\u0646 \u0648\u0635\u0641\u0629 \u0637\u0628\u064a\u0629 \u0648\u0627\u0644\u0641\u064a\u062a\u0627\u0645\u064a\u0646\u0627\u062a \u0648\u0627\u0644\u0645\u0639\u0627\u062f\u0646 \u0648\u0627\u0644\u0645\u0643\u0645\u0644\u0627\u062a \u0627\u0644\u0639\u0634\u0628\u064a\u0629 \u0627\u0644\u0645\u0633\u062a\u062e\u062f\u0645\u0629<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"otc-medications-supplements\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"otc-medications-supplements\"><\/textarea><\/span><\/label>\n\t<\/p>\n\t<h4>4- \u0628\u064a\u0627\u0646\u0627\u062a \u0627\u0644\u0645\u0628\u0644\u0651\u063a\n\t<\/h4>\n\t<p><label>\u0627\u0633\u0645 \u0627\u0644\u0645\u0628\u0644\u0651\u063a<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"reporter-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"reporter-name\" \/><\/span><\/label>\n\t<\/p>\n\t<p><label>\u0627\u0644\u0639\u0644\u0627\u0642\u0629 \u0628\u0627\u0644\u0645\u0631\u064a\u0636<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"reporter-relationship\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"reporter-relationship\" \/><\/span><\/label>\n\t<\/p>\n\t<p><label>\u0627\u0644\u0639\u0646\u0648\u0627\u0646<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"reporter-address\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"reporter-address\" \/><\/span><\/label>\n\t<\/p>\n\t<p><label>\u0631\u0642\u0645 \u0627\u0644\u0647\u0627\u062a\u0641<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"reporter-phone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"reporter-phone\" \/><\/span><\/label>\n\t<\/p>\n\t<p><label>\u0627\u0644\u0628\u0631\u064a\u062f \u0627\u0644\u0625\u0644\u0643\u062a\u0631\u0648\u0646\u064a<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"reporter-email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" autocomplete=\"email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"reporter-email\" \/><\/span><\/label>\n\t<\/p>\n\t<p><label>\u0647\u0644 \u062a\u0648\u0627\u0641\u0642 \u0639\u0644\u0649 \u0645\u0634\u0627\u0631\u0643\u0629 \u0647\u0630\u0647 \u0627\u0644\u0628\u064a\u0627\u0646\u0627\u062a \u0645\u0639 \u0627\u0644\u0634\u0631\u0643\u0629 \u0627\u0644\u0645\u0648\u0631\u062f\u0629\u061f<\/label>\n\t<\/p>\n\t<p>\u0645\u0634\u0627\u0631\u0643\u0629 \u0647\u0630\u0647 \u0627\u0644\u0628\u064a\u0627\u0646\u0627\u062a \u0645\u0639 \u0627\u0644\u0645\u0648\u0631\u062f \u0644\u0644\u0633\u0645\u0627\u062d \u0628\u0627\u0644\u062a\u0648\u0627\u0635\u0644 \u0641\u064a \u062d\u0627\u0644 \u0627\u0644\u062d\u0627\u062c\u0629 \u0625\u0644\u0649 \u0645\u0632\u064a\u062f \u0645\u0646 \u0627\u0644\u0628\u064a\u0627\u0646\u0627\u062a \u0641\u0642\u0637 \u0648\u0630\u0644\u0643 \u0644\u0623\u063a\u0631\u0627\u0636 \u062a\u0642\u064a\u064a\u0645 \u0648\u0645\u062a\u0627\u0628\u0639\u0629 \u0633\u0644\u0627\u0645\u0629 \u0627\u0644\u062f\u0648\u0627\u0621.\n\t<\/p>\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"supplier-data-sharing\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"supplier-data-sharing\" value=\"\u0646\u0639\u0645\" \/><span class=\"wpcf7-list-item-label\">\u0646\u0639\u0645<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"supplier-data-sharing\" value=\"\u0644\u0627\" \/><span class=\"wpcf7-list-item-label\">\u0644\u0627<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n\t<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"\u0625\u0631\u0633\u0627\u0644 \u0627\u0644\u062a\u0642\u0631\u064a\u0631\" \/>\n\t<\/p>\n<\/div><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<input type=\"hidden\" name=\"trp-form-language\" value=\"ar\"\/><\/form>\n<\/div>","protected":false},"excerpt":{"rendered":"","protected":false},"author":11,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"footnotes":""},"class_list":["post-1266","page","type-page","status-publish","hentry"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v28.5 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>test form - Ibnsina Pharma | Leading Pharmaceutical Distribution Company in Egypt<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/ibnsina-pharma.com\/ar\/test-form\/\" \/>\n<meta property=\"og:locale\" content=\"ar_AR\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"test form - Ibnsina Pharma | Leading Pharmaceutical Distribution Company in Egypt\" \/>\n<meta property=\"og:url\" content=\"https:\/\/ibnsina-pharma.com\/ar\/test-form\/\" \/>\n<meta property=\"og:site_name\" content=\"Ibnsina Pharma | Leading Pharmaceutical Distribution Company in Egypt\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\\\/\\\/schema.org\",\"@graph\":[{\"@type\":\"WebPage\",\"@id\":\"https:\\\/\\\/ibnsina-pharma.com\\\/test-form\\\/\",\"url\":\"https:\\\/\\\/ibnsina-pharma.com\\\/test-form\\\/\",\"name\":\"test form - Ibnsina Pharma | Leading Pharmaceutical Distribution Company in 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