[{"Name":"Data configuration","Title":"Data configuration","Type":"DataConfig","Children":[{"Name":null,"Title":null,"Label":"I confirm that I have been prescribed Wegovy^{^®} (semaglutide) for weight management by my treating healthcare professional.","Type":"DataField","Children":[]},{"Name":null,"Title":null,"Label":"Current Infusion Stage","Type":"DataField","Children":[]},{"Name":"Address","Title":"Address","InputType":"TextBox","Label":"Your street address","Type":"DataField","Children":[]},{"Name":"BestTimeToCall","Title":"BestTimeToCall","Label":"Preferred time for call:","InputType":"DropDownList","ParentID":8,"RequiredMessage":"This is a required field","Type":"DataField","Children":[{"Name":"252","Title":"Morning","Label":"Morning","Config":"","Type":"DataFieldOption","Children":[]},{"Name":"253","Title":"Afternoon","Label":"Afternoon","Config":"","Type":"DataFieldOption","Children":[]},{"Name":"254","Title":"Anytime ","Label":"Any Time ","Config":"","Type":"DataFieldOption","Children":[]}]},{"Name":"CarerEmailAddress","Title":"CarerEmailAddress","InputType":"TextBox","Label":"Carer’s email address","CustomValidation":"{\"Name\":\"email\",\"EditorLabel\":\"Email\",\"ValidateType\":\"rule\",\"Props\":[]}","CustomMessage":"Invalid email","Type":"DataField","Children":[]},{"Name":"CarerFirstName","Title":"CarerFirstName","InputType":"TextBox","Label":"Carer’s first name","ParentID":8,"Type":"DataField","Children":[]},{"Name":"CarerLastName","Title":"CarerLastName","InputType":"TextBox","Label":"Carer’s last name","Type":"DataField","Children":[]},{"Name":"CarerMobilePhone","Title":"CarerMobilePhone","InputType":"TextBox","Label":"Carer’s mobile number","Type":"DataField","Children":[]},{"Name":"CarerPrimaryContact","Title":"CarerPrimaryContact","InputType":"Checkbox","Label":"I would like to nominate a carer on behalf of patient","Type":"DataField","Children":[]},{"Name":"CarerRelationship","Title":"CarerRelationship","InputType":"DropDownList","Label":"Select the relationship type","ParentID":8,"Type":"DataField","Children":[{"Name":"895","Title":"Parent","Label":"Parent","Type":"DataFieldOption","Children":[]},{"Name":"897","Title":"Carer","Label":"Carer","Type":"DataFieldOption","Children":[]},{"Name":"898","Title":"Guardian","Label":"Guardian","Type":"DataFieldOption","Children":[]},{"Name":"899","Title":"Other","Label":"Other","Type":"DataFieldOption","Children":[]}]},{"Name":"ComfortableWithPhoneSupport","Title":"ComfortableWithPhoneSupport","InputType":"RadioButton","Label":"Are you comfortable to start with a Telehealth consult?

Our Telehealth nurse consults are conducted over the phone or video call to guide you through your injection.","ParentID":8,"RequiredMessage":"This is a required field","Type":"DataField","Children":[{"Name":"692","Title":"Yes","Label":"Yes","Type":"DataFieldOption","Children":[]},{"Name":"693","Title":"No","Label":"No","Type":"DataFieldOption","Children":[]}]},{"Name":"CommencingTreatment","Title":"CommencingTreatment","Label":"Will be commencing treatment?","InputType":"RadioButton","RequiredMessage":"This field is required","ParentID":8,"Type":"DataField","Children":[{"Name":"1808","Title":"Yes","Label":"Yes","Config":"","Type":"DataFieldOption","Children":[]},{"Name":"1809","Title":"No","Label":"No","Config":"","Type":"DataFieldOption","Children":[]}]},{"Name":"ConfirmApproved","Title":"ConfirmApproved","Label":"I confirm this patient has been approved to receive Belantamab mafodotin by GSK Medical and I have received confirmation by email.","InputType":"Checkbox","RequiredMessage":"This is a required field","Type":"DataField","Children":[]},{"Name":"ConfirmPassword","Title":"ConfirmPassword","InputType":"Password","Label":"Confirm your password","RequiredMessage":"This is a required field","Type":"DataField","Children":[]},{"Name":"ConfirmPatientHasHadFirstInjection","Title":"ConfirmPatientHasHadFirstInjection","InputType":"Checkbox","Label":"I confirm that I have had my first Nucala dose.","RequiredMessage":"This is a required field","Type":"DataField","Children":[]},{"Name":"ConfirmPrescribed","Title":"ConfirmPrescribed","InputType":"Checkbox","Label":"I confirm this patient has been prescribed belantamab mafodotin.","RequiredMessage":"This field is required.","Type":"DataField","Children":[]},{"Name":"ConfirmPrescriber","Title":"ConfirmPrescriber","Label":"I am the prescribing Healthcare Professional authorised to refer this patient.","InputType":"Checkbox","RequiredMessage":"This field is required.","Type":"DataField","Children":[]},{"Name":"ConfirmStayUpdatedOnGSK","Title":"ConfirmStayUpdatedOnGSK","InputType":"Checkbox","Type":"DataField","Children":[]},{"Name":"ConsentsToTCsAndPrivacyPolicy","Title":"ConsentsToTCsAndPrivacyPolicy","Label":"Consents to T&Cs and Privacy Policy","InputType":"RadioButton","RequiredMessage":"This is a required field","ParentID":8,"Type":"DataField","Children":[{"Name":"1817","Title":"Yes","Label":"Yes","Config":"","Type":"DataFieldOption","Children":[]},{"Name":"1818","Title":"No","Label":"No","Config":"","Type":"DataFieldOption","Children":[]}]},{"Name":"ContinuationDoseFrequency","Title":"ContinuationDoseFrequency","InputType":"DropDownList","Label":"Continuation Dose Frequency","ParentID":8,"Type":"DataField","Children":[{"Name":"1706","Title":"3 Week","Label":"3 Week","Type":"DataFieldOption","Children":[]},{"Name":"1707","Title":"4 Week","Label":"4 Week","Type":"DataFieldOption","Children":[]},{"Name":"1708","Title":"6 Week","Label":"6 Week","Config":"","Type":"DataFieldOption","Children":[]},{"Name":"1709","Title":"12 Week","Label":"12 Week","Config":"","Type":"DataFieldOption","Children":[]}]},{"Name":"CurrentDosingSchedule","Title":"CurrentDosingSchedule","InputType":"DropDownList","Label":"Current Dosing Schedule","RequiredMessage":"This field is required","ParentID":8,"Type":"DataField","Children":[{"Name":"1790","Title":"3 Week","Label":"3 Week","Config":"","Type":"DataFieldOption","Children":[]},{"Name":"1791","Title":"4 Week","Label":"4 Week","Config":"","Type":"DataFieldOption","Children":[]},{"Name":"1792","Title":"6 Week","Label":"6 Week","Config":"","Type":"DataFieldOption","Children":[]},{"Name":"1793","Title":"12 Week","Label":"12 Week","Config":"","Type":"DataFieldOption","Children":[]}]},{"Name":"CurrentInfusionStage","Title":"CurrentInfusionStage","InputType":"DropDownList","Label":"Current Infusion Stage","RequiredMessage":"This field is required","ParentID":8,"Type":"DataField","Children":[{"Name":"1797","Title":"1","Label":"1","Config":"","Type":"DataFieldOption","Children":[]},{"Name":"1798","Title":"2","Label":"2","Config":"","Type":"DataFieldOption","Children":[]},{"Name":"1799","Title":"3","Label":"3","Config":"","Type":"DataFieldOption","Children":[]},{"Name":"1800","Title":"4","Label":"4","Config":"","Type":"DataFieldOption","Children":[]},{"Name":"1801","Title":"Completed","Label":"Completed","Config":"","Type":"DataFieldOption","Children":[]}]},{"Name":"DateOfBirth","Title":"DateOfBirth","Label":"Date of birth","RequiredMessage":"This is a required field","ParentID":8,"InputType":"Date","Type":"DataField","Children":[]},{"Name":"DaytimePhone","Title":"DaytimePhone","Label":"Phone / mobile number","InputType":"TextBox","RequiredMessage":"This is a required field","Type":"DataField","Children":[]},{"Name":"Delegate1Email","Title":"Delegate1Email","InputType":"TextBox","CustomValidation":"{\"Name\":\"email\",\"EditorLabel\":\"Email\",\"ValidateType\":\"rule\",\"Props\":[]}","Label":"Delegate 1 email address","Type":"DataField","Children":[]},{"Name":"Delegate1First","Title":"Delegate1First","InputType":"TextBox","Label":"Delegate 1 first name","Type":"DataField","Children":[]},{"Name":"Delegate1Last","Title":"Delegate1Last","InputType":"TextBox","Label":"Delegate 1 last name","Type":"DataField","Children":[]},{"Name":"Delegate2Email","Title":"Delegate2Email","InputType":"TextBox","CustomValidation":"{\"Name\":\"email\",\"EditorLabel\":\"Email\",\"ValidateType\":\"rule\",\"Props\":[]}","Label":"Delegate 2 email address","Type":"DataField","Children":[]},{"Name":"Delegate2First","Title":"Delegate2First","Label":"Delegate 2 first name","InputType":"TextBox","Type":"DataField","Children":[]},{"Name":"Delegate2Last","Title":"Delegate2Last","InputType":"TextBox","Label":"Delegate 2 last name","Type":"DataField","Children":[]},{"Name":"DelegateEmail","Title":"DelegateEmail","Label":"Delegate Email","InputType":"TextBox","Type":"DataField","Children":[]},{"Name":"Dosage","Title":"Dosage","InputType":"DropDownList","Label":"What dose of Nucala^{^®} are you on?","RequiredMessage":"This is a required field.","ParentID":8,"Type":"DataField","Children":[{"Name":"1172","Title":"0.25mg","Label":"0.25mg","Type":"DataFieldOption","Children":[]},{"Name":"1173","Title":"0.50mg","Label":"0.50mg","Type":"DataFieldOption","Children":[]},{"Name":"1179","Title":"1mg","Label":"1mg","Config":"","Type":"DataFieldOption","Children":[]}]},{"Name":"Dose","Title":"Dose","Label":"Dose","InputType":"RadioButton","RequiredMessage":"This field is required","ParentID":8,"Type":"DataField","Children":[{"Name":"1804","Title":"Initiation Dose","Label":"Initiation Dose","Config":"","Type":"DataFieldOption","Children":[]},{"Name":"1805","Title":"Continuation Dose","Label":"Continuation Dose","Config":"","Type":"DataFieldOption","Children":[]}]},{"Name":"DrugLookup","Title":"DrugLookup","InputType":"TextBox","Label":"Please type in the first three (3) letters of your GSK treatment below:","RequiredMessage":"This is a required field","ParentID":8,"Type":"DataField","Children":[{"Name":"1358","Title":"DataFieldOption","Label":"","Config":"","Type":"DataFieldOption","Children":[]}]},{"Name":"Email","Title":"Email","InputType":"TextBox","ParentID":8,"Label":"Email address","CustomValidation":"{\"Name\":\"email\",\"EditorLabel\":\"Email\",\"ValidateType\":\"rule\",\"Props\":[]}","RequiredMessage":"This is a required field","CustomMessage":"Please enter a valid email address","Type":"DataField","Children":[]},{"Name":"FirstName","Title":"FirstName","InputType":"TextBox","Label":"First name","RequiredMessage":"This is a required field","Type":"DataField","Children":[]},{"Name":"FutureDateTest","Title":"FutureDateTest","InputType":"Date","CustomValidation":"{\"Name\":\"futuredate\",\"EditorLabel\":\"Future Date\",\"ValidateType\":\"rule\",\"Props\":[]}","CustomMessage":"This must be a date 13 days in the future or more","Config":"15","Type":"DataField","Children":[]},{"Name":"Gender","Title":"Gender","InputType":"DropDownList","Label":"Select your gender","ParentID":8,"Type":"DataField","Children":[{"Name":"58","Title":"Male","Label":"Male","Type":"DataFieldOption","Children":[]},{"Name":"59","Title":"Female","Label":"Female","Type":"DataFieldOption","Children":[]},{"Name":"60","Title":"Prefer not to say","Label":"Prefer not to say","Type":"DataFieldOption","Children":[]}]},{"Name":"HadFirstInjection","Title":"HadFirstInjection","InputType":"RadioButton","Label":"Have you started your Nucala treatment?","ParentID":8,"RequiredMessage":"This is a required field","Type":"DataField","Children":[{"Name":"688","Title":"Yes","Label":"Yes","Config":"","Type":"DataFieldOption","Children":[]},{"Name":"689","Title":"No","Label":"No","Config":"","Type":"DataFieldOption","Children":[]}]},{"Name":"HasReceivedPrescription","Title":"HasReceivedPrescription","ParentID":8,"Label":"Before we can organise a time for your training you will need to have your script. Have you received your Nucala script?","RequiredMessage":"This is a required field","InputType":"RadioButton","Type":"DataField","Children":[{"Name":"685","Title":"Yes","Label":"Yes","Config":"","Type":"DataFieldOption","Children":[]},{"Name":"686","Title":"No","Label":"Not yet","Config":"","Type":"DataFieldOption","Children":[]}]},{"Name":"HCPClinicName","Title":"HCPClinicName","Type":"DataField","Children":[]},{"Name":"HCPConsentsToPrivacyPolicyTermsAndConditions","Title":"HCPConsentsToPrivacyPolicyTermsAndConditions","InputType":"Checkbox","Type":"DataField","Children":[]},{"Name":"HCPFirstName","Title":"HCPFirstName","InputType":"TextBox","Label":"Your specialist's first name*","RequiredMessage":"Your specialist's first name","Type":"DataField","Children":[]},{"Name":"HCPLastName","Title":"HCPLastName","InputType":"TextBox","Label":"Your specialist's last name*","RequiredMessage":"Your specialist's last name","Type":"DataField","Children":[]},{"Name":"HCPNominateCarer","Title":"HCPNominateCarer","Label":"I would like to nominate a carer / guardian / parent on behalf of the patient.","InputType":"Checkbox","Config":"","RequiredMessage":"","CustomValidation":"","CustomMessage":"","ToolTipText":"","Type":"DataField","Children":[]},{"Name":"HCPPhone","Title":"HCPPhone","InputType":"TextBox","Label":"Your specialist's phone number","RequiredMessage":"Your clinic / practice phone number","Type":"DataField","Children":[]},{"Name":"IHaveBeenPrescribedBelantamabMafodotinByAHealthcareProfessional","Title":"IHaveBeenPrescribedBelantamabMafodotinByAHealthcareProfessional","InputType":"Checkbox","Label":"I have been prescribed Belantamab mafodotin by a healthcare professional","RequiredMessage":"This is a required field","Type":"DataField","Children":[]},{"Name":"INCEPTUANumber","Title":"INCEPTUANumber","Label":"INCEPTUA Number","InputType":"TextBox","CustomValidation":"{\"Name\":\"number\",\"EditorLabel\":\"number\",\"ValidateType\":\"val\",\"Props\":[]}","CustomMessage":"Please type a number","Type":"DataField","Children":[]},{"Name":"Indication","Title":"Indication","InputType":"ButtonGroup","Label":"What have you been prescribed the treatment for?","RequiredMessage":"This is a required field","ParentID":8,"Type":"DataField","Children":[{"Name":"154","Title":"SEA","Label":"Severe eosinophilic asthma (SEA)","Type":"DataFieldOption","Children":[]},{"Name":"892","Title":"NasalPolyps","Label":"Chronic rhinosinusitis with nasal polyps (CRSwNP)","Type":"DataFieldOption","Children":[]},{"Name":"1662","Title":"EGPA","Label":"Eosinophilic granulomatosis with polyangiitis (EGPA)","Config":"","Type":"DataFieldOption","Children":[]},{"Name":"1663","Title":"HES","Label":"Hypereosinophilic syndrome (HES)","Config":"","Type":"DataFieldOption","Children":[]}]},{"Name":"IndicationText","Title":"IndicationText","InputType":"TextBox","Label":"I am taking a GSK medication for the following condition:","Type":"DataField","Children":[]},{"Name":"InfusionDate1","Title":"InfusionDate1","Label":"Scheduled infusion date (dd/mm/yyyy)","InputType":"Date","ParentID":8,"RequiredMessage":"This field is required","Type":"DataField","Children":[]},{"Name":"InitialDoseFrequency","Title":"InitialDoseFrequency","ParentID":8,"InputType":"DropDownList","Label":"Initial Dose Frequency","Type":"DataField","Children":[{"Name":"1703","Title":"3 Week","Label":"3 Week","Config":"","Type":"DataFieldOption","Children":[]},{"Name":"1704","Title":"4 Week","Label":"4 Week","Config":"","Type":"DataFieldOption","Children":[]}]},{"Name":"LastName","Title":"LastName","InputType":"TextBox","Label":"Last name","RequiredMessage":"This is a required field","Type":"DataField","Children":[]},{"Name":"MobilePhone","Title":"MobilePhone","InputType":"TextBox","Label":"Mobile number","ParentID":8,"CustomMessage":"Enter valid mobile aus no.","RequiredMessage":"This is a required field","Type":"DataField","Children":[]},{"Name":"MobilePhoneTwo","Title":"MobilePhoneTwo","InputType":"TextBox","CustomValidation":"{\"Name\":\"phone\",\"EditorLabel\":\"Phone\",\"ValidateType\":\"rule\",\"Props\":[]}","Label":"Mobile Number Two","Type":"DataField","Children":[]},{"Name":"NextInjectionDate","Title":"NextInjectionDate","InputType":"Date","Label":"Next date for Nucala injection","RequiredMessage":"This is a required field","Type":"DataField","Children":[]},{"Name":"NextScriptCollectionDate","Title":"NextScriptCollectionDate","InputType":"Date","Label":"Next date for script collection","RequiredMessage":"This is a required field","Type":"DataField","Children":[]},{"Name":"NominateCarer","Title":"NominateCarer","Label":"I would like to nominate a carer on my behalf / I am the carer / parent to a patient under 18 years of age.","InputType":"Checkbox","ParentID":8,"Type":"DataField","Children":[]},{"Name":"OldPassword","Title":"OldPassword","InputType":"Password","Label":"Current password","Type":"DataField","Children":[]},{"Name":"Password","Title":"Password","InputType":"Password","Label":"Set your password","RequiredMessage":"This is a required field","CustomMessage":"Passwords must be at least 6 characters long and have an uppercase character and a symbol","Type":"DataField","Children":[]},{"Name":"PatientAcceptsTCsAndPrivacyPolicy","Title":"PatientAcceptsTCsAndPrivacyPolicy","Label":"I have reviewed and agree with the MyeCare Program Terms & Conditions and Privacy Notice","InputType":"Checkbox","RequiredMessage":"This is a required field","Type":"DataField","Children":[]},{"Name":"PatientAvailabilityDays","Title":"PatientAvailabilityDays","Label":"Preferred day of the week for call:","InputType":"CheckBoxList","ParentID":8,"RequiredMessage":"This is a required field","Type":"DataField","Children":[{"Name":"245","Title":"Monday","Label":"Monday","Config":"","Type":"DataFieldOption","Children":[]},{"Name":"246","Title":"Tuesday","Label":"Tuesday","Config":"","Type":"DataFieldOption","Children":[]},{"Name":"247","Title":"Wednesday","Label":"Wednesday","Config":"","Type":"DataFieldOption","Children":[]},{"Name":"248","Title":"Thursday","Label":"Thursday","Config":"","Type":"DataFieldOption","Children":[]},{"Name":"249","Title":"Friday","Label":"Friday","Config":"","Type":"DataFieldOption","Children":[]}]},{"Name":"PatientConfirmPrescribed","Title":"PatientConfirmPrescribed","Label":"I have been prescribed Belantamab mafodotin by a healthcare professional","InputType":"Checkbox","RequiredMessage":"This field is required","Type":"DataField","Children":[]},{"Name":"PatientConsentProvided","Title":"PatientConsentProvided","InputType":"Checkbox","Label":"The patient has given consent for me to convey the above contact information to the MyeCare Program team and consents to contact by email and telephone to complete enrolment.","RequiredMessage":"This is a required field","ParentID":8,"Type":"DataField","Children":[]},{"Name":"Postcode","Title":"Postcode","InputType":"TextBox","Label":"Enter your postcode","CustomValidation":"{\"Name\":\"password\",\"EditorLabel\":\"Aus postcode\",\"ValidateType\":\"val\",\"Props\":[{\"Item1\":\"max\",\"Item2\":\"4\"},{\"Item1\":\"regex\",\"Item2\":\"[0-9]{4}\"}]}","CustomMessage":"Please enter a valid postcode.","Type":"DataField","Children":[]},{"Name":"PreferredCDESessionType","Title":"PreferredCDESessionType","InputType":"DropDownList","Label":"Preferred type of education session","RequiredMessage":"This is a required field","ParentID":8,"Type":"DataField","Children":[{"Name":"1113","Title":"In-clinic","Label":"In-clinic","Type":"DataFieldOption","Children":[]},{"Name":"1114","Title":"Virtual","Label":"Virtual","Type":"DataFieldOption","Children":[]}]},{"Name":"PreferredDateForTraining","Title":"PreferredDateForTraining","InputType":"Date","Label":"Set the preferred date on which you would like the education session","RequiredMessage":"This is a required field","Type":"DataField","Children":[]},{"Name":"PreferredDayOfWeekForTraining","Title":"PreferredDayOfWeekForTraining","InputType":"CheckBoxList","Label":"Preferred day of week for training","ParentID":8,"RequiredMessage":"This is a required field","Type":"DataField","Children":[{"Name":"653","Title":"Monday","Label":"Monday","Type":"DataFieldOption","Children":[]},{"Name":"654","Title":"Tuesday","Label":"Tuesday","Type":"DataFieldOption","Children":[]},{"Name":"655","Title":"Wednesday","Label":"Wednesday","Type":"DataFieldOption","Children":[]},{"Name":"656","Title":"Thursday","Label":"Thursday","Type":"DataFieldOption","Children":[]},{"Name":"657","Title":"Friday","Label":"Friday","Config":"","Type":"DataFieldOption","Children":[]},{"Name":"658","Title":"Weekend","Label":"Weekend","Config":"","Type":"DataFieldOption","Children":[]}]},{"Name":"PreferredReminder","Title":"PreferredReminder","Label":"How would you like to receive your reminders?","RequiredMessage":"This is a required field","InputType":"DropDownList","ParentID":8,"Type":"DataField","Children":[{"Name":"344","Title":"Email","Label":"Email only","Config":"","Type":"DataFieldOption","Children":[]},{"Name":"345","Title":"SMS","Label":"SMS only","Config":"","Type":"DataFieldOption","Children":[]},{"Name":"346","Title":"Both","Label":"Both Email & SMS","Config":"","Type":"DataFieldOption","Children":[]}]},{"Name":"PreferredTimeForTraining","Title":"PreferredTimeForTraining","InputType":"DropDownList","Label":"What is the best time of day for the education session?","ParentID":8,"RequiredMessage":"This is a required field","Type":"DataField","Children":[{"Name":"660","Title":"Morning","Label":"Morning","Config":"","Type":"DataFieldOption","Children":[]},{"Name":"661","Title":"Afternoon","Label":"Afternoon","Config":"","Type":"DataFieldOption","Children":[]},{"Name":"662","Title":"Evening","Label":"Evening","Config":"","Type":"DataFieldOption","Children":[]}]},{"Name":"PrescriberConfirmPrescribingHcp","Title":"PrescriberConfirmPrescribingHcp","InputType":"Checkbox","Label":"I am the prescribing healthcare professional for this patient (do not check the box if not)","Type":"DataField","Children":[]},{"Name":"PrescriberConsent","Title":"PrescriberConsent","InputType":"Checkbox","RequiredMessage":"This is a required field","Label":"I consent to the collection, use and disclosure of my personal information.","Type":"DataField","Children":[]},{"Name":"PrescriberConsentReceiveCommunication","Title":"PrescriberConsentReceiveCommunication","InputType":"Checkbox","Label":"I consent to receive updates about my patient’s progress and broader communications from GSK. I understand that my personal information will be handled in accordance with GSK’s privacy policy as outlined above and I may withdraw my consent at any time","Type":"DataField","Children":[]},{"Name":"PrescriberEmail","Title":"PrescriberEmail","InputType":"TextBox","Label":"Your email address","RequiredMessage":"This is a required field.","CustomValidation":"{\"Name\":\"email\",\"EditorLabel\":\"Email\",\"ValidateType\":\"rule\",\"Props\":[]}","CustomMessage":"Invalid email","Type":"DataField","Children":[]},{"Name":"PrescriberFirstName","Title":"PrescriberFirstName","InputType":"TextBox","Label":"Your first name","RequiredMessage":"This is a required field","Type":"DataField","Children":[]},{"Name":"PrescriberLastName","Title":"PrescriberLastName","InputType":"TextBox","Label":"Your last name","RequiredMessage":"This is a required field","Type":"DataField","Children":[]},{"Name":"PrescriberMobile","Title":"PrescriberMobile","InputType":"TextBox","Label":"Your mobile number","RequiredMessage":"This is a required field","Type":"DataField","Children":[]},{"Name":"PrescriberPracticeAddress","Title":"PrescriberPracticeAddress","InputType":"TextBox","Label":"Your clinic / practice street address","ParentID":8,"Type":"DataField","Children":[{"Name":"1344","Title":"DataFieldOption","Label":"","Config":"","Type":"DataFieldOption","Children":[]}]},{"Name":"PrescriberPracticeName","Title":"PrescriberPracticeName","InputType":"TextBox","Label":"Clinic / hospital name","RequiredMessage":"This is a required field","Type":"DataField","Children":[]},{"Name":"PrescriberPracticePhoneNumber","Title":"PrescriberPracticePhoneNumber","InputType":"TextBox","Label":"Clinic / hospital phone number","RequiredMessage":"This is a required field.","CustomValidation":"{\"Name\":\"ausmobile\",\"EditorLabel\":\"Aus mobile number\",\"ValidateType\":null,\"Props\":[{\"Item1\":\"min\",\"Item2\":\"10\"},{\"Item1\":\"regex\",\"Item2\":\"^((61|\\\\+61)?\\\\s?)04[0-9]{2}\\\\s?([0-9]{3}\\\\s?[0-9]{3}|[0-9]{2}\\\\s?[0-9]{2}\\\\s?[0-9]{2})$\"}]}","CustomMessage":"Invalid phone number","Type":"DataField","Children":[]},{"Name":"PrescriberPracticePostcode","Title":"PrescriberPracticePostcode","InputType":"Number","Label":"Clinic / hospital postcode","RequiredMessage":"This is a required field","CustomValidation":"{\"Name\":\"password\",\"EditorLabel\":\"Aus postcode\",\"ValidateType\":\"val\",\"Props\":[{\"Item1\":\"max\",\"Item2\":\"4\"},{\"Item1\":\"regex\",\"Item2\":\"[0-9]{4}\"}]}","CustomMessage":"Please enter a valid postcode","Type":"DataField","Children":[]},{"Name":"PrescriberPracticeState","Title":"PrescriberPracticeState","InputType":"DropDownList","Label":"Clinic / hospital state","RequiredMessage":"This is a required field","ParentID":8,"Type":"DataField","Children":[{"Name":"1229","Title":"Auckland","Label":"Auckland","Type":"DataFieldOption","Children":[]},{"Name":"1230","Title":"Canterbury","Label":"Canterbury","Type":"DataFieldOption","Children":[]},{"Name":"1231","Title":"Wellington","Label":"Wellington","Type":"DataFieldOption","Children":[]},{"Name":"1232","Title":"Waikato","Label":"Waikato","Type":"DataFieldOption","Children":[]},{"Name":"1233","Title":"Bay of Plenty","Label":"Bay of Plenty","Type":"DataFieldOption","Children":[]},{"Name":"1234","Title":"Manawatu-Wanganui","Label":"Manawatu-Wanganui","Type":"DataFieldOption","Children":[]},{"Name":"1235","Title":"Otago","Label":"Otago","Type":"DataFieldOption","Children":[]},{"Name":"1236","Title":"Hawke's Bay","Label":"Hawke's Bay","Type":"DataFieldOption","Children":[]},{"Name":"1654","Title":"Northland","Label":"Northland","Type":"DataFieldOption","Children":[]},{"Name":"1655","Title":"Taranaki","Label":"Taranaki","Config":"","Type":"DataFieldOption","Children":[]},{"Name":"1656","Title":"Southland","Label":"Southland","Config":"","Type":"DataFieldOption","Children":[]},{"Name":"1657","Title":"Nelson","Label":"Nelson","Config":"","Type":"DataFieldOption","Children":[]},{"Name":"1658","Title":"Gisborne","Label":"Gisborne","Config":"","Type":"DataFieldOption","Children":[]},{"Name":"1659","Title":"Marlborough","Label":"Marlborough","Config":"","Type":"DataFieldOption","Children":[]},{"Name":"1660","Title":"Tasman","Label":"Tasman","Config":"","Type":"DataFieldOption","Children":[]},{"Name":"1661","Title":"West Coast","Label":"West Coast","Config":"","Type":"DataFieldOption","Children":[]}]},{"Name":"PrescriberReceivedPatientConsent","Title":"PrescriberReceivedPatientConsent","InputType":"Checkbox","Label":"The patient has given consent for me to convey the above contact information to the MyeCare Program Team and consents to contact by email and telephone to complete enrolment*","RequiredMessage":"This is a required field","Type":"DataField","Children":[]},{"Name":"PrescriberState","Title":"PrescriberState","Label":"Business or practice region","ParentID":8,"InputType":"DropDownList","RequiredMessage":"This is a required field","Type":"DataField","Children":[{"Name":"1744","Title":"NSW","Label":"NSW","Config":"","Type":"DataFieldOption","Children":[]},{"Name":"1745","Title":"VIC","Label":"VIC","Config":"","Type":"DataFieldOption","Children":[]},{"Name":"1746","Title":"SA","Label":"SA","Config":"","Type":"DataFieldOption","Children":[]},{"Name":"1747","Title":"ACT","Label":"ACT","Config":"","Type":"DataFieldOption","Children":[]},{"Name":"1748","Title":"QLD","Label":"QLD","Config":"","Type":"DataFieldOption","Children":[]},{"Name":"1749","Title":"NT","Label":"NT","Config":"","Type":"DataFieldOption","Children":[]},{"Name":"1750","Title":"TAS","Label":"TAS","Config":"","Type":"DataFieldOption","Children":[]},{"Name":"1751","Title":"WA","Label":"WA","Config":"","Type":"DataFieldOption","Children":[]}]},{"Name":"PrescriberType","Title":"PrescriberType","InputType":"DropDownList","Label":"Business or professional type","ParentID":8,"RequiredMessage":"This is a required field","Type":"DataField","Children":[{"Name":"966","Title":"Endocrinologist","Label":"Endocrinologist","Type":"DataFieldOption","Children":[]},{"Name":"967","Title":"General practitioner","Label":"General practitioner","Type":"DataFieldOption","Children":[]},{"Name":"969","Title":"Nurse practitioner","Label":"Nurse practitioner","Type":"DataFieldOption","Children":[]},{"Name":"970","Title":"Registered Nurse","Label":"Registered Nurse","Type":"DataFieldOption","Children":[]}]},{"Name":"ProductBarcode","Title":"ProductBarcode","InputType":"TextBox","Label":"Type in the first three (3) letters of your treatment name","RequiredMessage":"This is a required field","Type":"DataField","Children":[]},{"Name":"RegisteredQualifiedHCP","Title":"RegisteredQualifiedHCP","InputType":"Checkbox","Type":"DataField","Children":[]},{"Name":"SpecialistNotFound","Title":"SpecialistNotFound","InputType":"Checkbox","Label":"Can’t find your prescribing specialist?","Type":"DataField","Children":[]},{"Name":"State","Title":"State","InputType":"DropDownList","Label":"Select your region","ParentID":8,"Type":"DataField","Children":[{"Name":"96","Title":"Auckland","Label":"Auckland","Type":"DataFieldOption","Children":[]},{"Name":"97","Title":"Canterbury","Label":"Canterbury","Type":"DataFieldOption","Children":[]},{"Name":"98","Title":"Wellington","Label":"Wellington","Type":"DataFieldOption","Children":[]},{"Name":"99","Title":"Waikato","Label":"Waikato","Type":"DataFieldOption","Children":[]},{"Name":"100","Title":"Bay of Plenty","Label":"Bay of Plenty","Type":"DataFieldOption","Children":[]},{"Name":"101","Title":"Manawatu-Wanganui","Label":"Manawatu-Wanganui","Type":"DataFieldOption","Children":[]},{"Name":"102","Title":"Otago","Label":"Otago","Type":"DataFieldOption","Children":[]},{"Name":"103","Title":"Hawke's Bay","Label":"Hawke's Bay","Type":"DataFieldOption","Children":[]},{"Name":"1664","Title":"Northland","Label":"Northland","Config":"","Type":"DataFieldOption","Children":[]},{"Name":"1665","Title":"Taranaki","Label":"Taranaki","Config":"","Type":"DataFieldOption","Children":[]},{"Name":"1666","Title":"Southland","Label":"Southland","Config":"","Type":"DataFieldOption","Children":[]},{"Name":"1667","Title":"Nelson","Label":"Nelson","Config":"","Type":"DataFieldOption","Children":[]},{"Name":"1668","Title":"Gisborne","Label":"Gisborne","Config":"","Type":"DataFieldOption","Children":[]},{"Name":"1669","Title":"Marlborough","Label":"Marlborough","Config":"","Type":"DataFieldOption","Children":[]},{"Name":"1670","Title":"Tasman","Label":"Tasman","Config":"","Type":"DataFieldOption","Children":[]},{"Name":"1671","Title":"West Coast","Label":"West Coast","Config":"","Type":"DataFieldOption","Children":[]}]},{"Name":"Suburb","Title":"Suburb","InputType":"TextBox","Label":"Suburb","RequiredMessage":"This is a required field","Type":"DataField","Children":[]},{"Name":"TellAboutSpecialist","Title":"TellAboutSpecialist","InputType":"Checkbox","Label":"Tell us about your specialist

This information will allow us to let your prescribing specialist know about your treatment progress.","Type":"DataField","Children":[]},{"Name":"TestConfigField","Title":"TestConfigField","Type":"DataField","Children":[]},{"Name":"TestField","Title":"TestField","InputType":"Number","CustomValidation":"{\"Name\":\"number\",\"EditorLabel\":\"number\",\"ValidateType\":\"val\",\"Props\":[]}","Config":"6","Label":"Test PostCode","CustomMessage":"Enter valid text","Type":"DataField","Children":[]},{"Name":"TherapyConfirmation","Title":"TherapyConfirmation","InputType":"Checkbox","Label":"I confirm I have been prescibed Nucala","RequiredMessage":"This is a required field","Type":"DataField","Children":[]},{"Name":"TimeOnTreatment","Title":"TimeOnTreatment","InputType":"ButtonGroup","Label":"Time on treatment","ParentID":8,"Type":"DataField","Children":[{"Name":"62","Title":"Not Yet started","Label":"Not yet started","Type":"DataFieldOption","Children":[]},{"Name":"94","Title":"Less than 4 months","Label":"Less than 4 months","Type":"DataFieldOption","Children":[]},{"Name":"95","Title":"4-12 months","Label":"4 to 12 months","Type":"DataFieldOption","Children":[]},{"Name":"836","Title":"More than 12 months","Label":"More than 12 months","Type":"DataFieldOption","Children":[]}]},{"Name":"Timezone","Title":"Timezone","InputType":"DropDownList","Label":"Your timezone","ParentID":8,"RequiredMessage":"This is a required field","Type":"DataField","Children":[{"Name":"238","Title":"AUS Eastern Standard Time","Label":"AUS Eastern Standard Time- Canberra, Melbourne, Sydney","Config":"","Type":"DataFieldOption","Children":[]},{"Name":"239","Title":"E. Australia Standard Time","Label":"E. Australia Standard Time- Brisbane","Config":"","Type":"DataFieldOption","Children":[]},{"Name":"240","Title":"Cen. Australia Standard Time","Label":"Cen. Australia Standard Time - Adelaide","Config":"","Type":"DataFieldOption","Children":[]},{"Name":"241","Title":"W. Australia Standard Time","Label":"W. Australia Standard Time- Perth","Config":"","Type":"DataFieldOption","Children":[]},{"Name":"242","Title":"Tasmania Standard Time","Label":"Tasmania Standard Time","Config":"","Type":"DataFieldOption","Children":[]},{"Name":"243","Title":"West Pacific Standard Time","Label":"West Pacific Standard Time - Guam, Port Moresby","Config":"","Type":"DataFieldOption","Children":[]}]},{"Name":"TreatmentConfidenceLevel","Title":"TreatmentConfidenceLevel","InputType":"ButtonGroup","Label":"Tell us how confident you feel in managing your treatment by selecting a face below:","ParentID":8,"Type":"DataField","Children":[{"Name":"945","Title":"VeryConcerned","Label":"Very concerned","Config":"Image:https://cdn.partizanhealth.com/novo/novo/Images/Emoji-Very-Concerned.svg","Type":"DataFieldOption","Children":[]},{"Name":"946","Title":"Concerned","Label":"Concerned","Type":"DataFieldOption","Children":[]},{"Name":"947","Title":"NotSure","Label":"Not sure","Type":"DataFieldOption","Children":[]},{"Name":"948","Title":"SomeWhatConfident","Label":"Some what confident","Type":"DataFieldOption","Children":[]},{"Name":"949","Title":"VeryConfident","Label":"Very confident","Config":"Image:https://cdn.partizanhealth.com/novo/novo/Images/Emoji-Very-Confident.svg","Type":"DataFieldOption","Children":[]}]},{"Name":"TreatmentConfirmation","Title":"TreatmentConfirmation","InputType":"Checkbox","Label":"I have been prescribed Belantamab mafodotin by a healthcare professional","RequiredMessage":"This is a required field","Type":"DataField","Children":[]},{"Name":"TreatmentName","Title":"TreatmentName","InputType":"ButtonGroup","Label":"Patient’s therapy","RequiredMessage":"Please select your medicine","ParentID":8,"Type":"DataField","Children":[{"Name":"166","Title":"Blenrep","Label":"belantamab mafodotin","Type":"DataFieldOption","Children":[]},{"Name":"874","Title":"NONE/UNCONFIRMED","Label":"Can't find my product","Type":"DataFieldOption","Children":[]}]},{"Name":"TreatmentText","Title":"TreatmentText","InputType":"TextBox","Label":"Patient's therapy

","Type":"DataField","Children":[]},{"Name":"Username","Title":"Username","InputType":"TextBox","Type":"DataField","Children":[]}]},{"Name":"Services","Title":"Services","Type":"ServiceWarehouse","Children":[{"Name":"EnrolService","Title":"EnrolService","MainTitle":"Enrol as a patient","ParentID":20,"ApiTypeID":"Enrolment","SubmitButtonLabel":"Enrol now","ServiceSuccessMsg":"

You have successfully enrolled!

You have successfully enrolled into the MyeCare Patient Support Programme.

You will soon receive a call from one of the MyeCare6 programme coordinators to give you an overview of the programme and provide you with details on how to access the app.

\n","ServiceBody":"

Enrol as a patient

Tell us about you:

Please note that fields with * are mandatory.

\n","Type":"EnrolService","Children":[{"Name":"74","Title":"FirstName","ColumnWidth":6,"DataField":"FirstName","RequiredMessage":"This is a required field","Type":"FormFieldPart","Children":[{"Name":"1812","Title":"Suburb","DataField":"Suburb","Type":"FormFieldPart","Children":[]}]},{"Name":"75","Title":"LastName","ColumnWidth":6,"DataField":"LastName","RequiredMessage":"This is a required field","Type":"FormFieldPart","Children":[]},{"Name":"78","Title":"Email","DataField":"Email","RequiredMessage":"This is a required field","ColumnWidth":6,"Type":"FormFieldPart","Children":[]},{"Name":"1239","Title":"MobilePhone","DataField":"MobilePhone","ColumnWidth":6,"RequiredMessage":"This is a required field","Type":"FormFieldPart","Children":[]},{"Name":"843","Title":"DateOfBirth","ColumnWidth":6,"DataField":"DateOfBirth","Type":"FormFieldPart","Children":[]},{"Name":"1783","Title":"CarerPrimaryContact","ToggleFields":"CarerLastName,CarerFirstName,CarerRelationship,CarerEmailAddress,CarerMobilePhone","ToggleValues":"on","DataField":"CarerPrimaryContact","Type":"FormFieldPart","Children":[]},{"Name":"1247","Title":"CarerRelationship","DataField":"CarerRelationship","AltLabel":"Carer's relationship to the patient","Type":"FormFieldPart","Children":[]},{"Name":"1244","Title":"CarerFirstName","DataField":"CarerFirstName","ColumnWidth":6,"Type":"FormFieldPart","Children":[]},{"Name":"1246","Title":"CarerLastName","DataField":"CarerLastName","ColumnWidth":6,"Type":"FormFieldPart","Children":[]},{"Name":"1268","Title":"CarerEmailAddress","DataField":"CarerEmailAddress","ColumnWidth":6,"Type":"FormFieldPart","Children":[]},{"Name":"1269","Title":"CarerMobilePhone","DataField":"CarerMobilePhone","ColumnWidth":6,"Type":"FormFieldPart","Children":[]},{"Name":"1317","Title":"PrescriberPracticeName","ColumnWidth":6,"DataField":"PrescriberPracticeName","ToggleFields":"GPClinicName,GPClinicOhoneNumber,GPClinicHCPFirstName,GPClinicHCPLastName","ToggleValues":"on","AltLabel":"The clinic name","Type":"FormFieldPart","Children":[]},{"Name":"1319","Title":"PrescriberPracticePhoneNumber","ColumnWidth":6,"DataField":"PrescriberPracticePhoneNumber","AltLabel":"Your specialist's phone number","Type":"FormFieldPart","Children":[]},{"Name":"1320","Title":"PrescriberFirstName","ColumnWidth":6,"DataField":"PrescriberFirstName","AltLabel":"Your specialist's first name","Type":"FormFieldPart","Children":[]},{"Name":"1321","Title":"PrescriberLastName","ColumnWidth":6,"DataField":"PrescriberLastName","AltLabel":"Your specialist's last name","Type":"FormFieldPart","Children":[]},{"Name":"854","Title":"PatientConsentProvided","DataField":"PatientConsentProvided","RequiredMessage":"Please confirm","Type":"FormFieldPart","Children":[]},{"Name":"1787","Title":"TreatmentName","DataField":"TreatmentName","Type":"FormFieldPart","Children":[]},{"Name":"1813","Title":"State","DataField":"State","Type":"FormFieldPart","Children":[]},{"Name":"1814","Title":"Postcode","DataField":"Postcode","Type":"FormFieldPart","Children":[]},{"Name":"1819","Title":"ConsentsToTCsAndPrivacyPolicy","DataField":"ConsentsToTCsAndPrivacyPolicy","Type":"FormFieldPart","Children":[]},{"Name":"1820","Title":"TreatmentConfirmation","DataField":"TreatmentConfirmation","Type":"FormFieldPart","Children":[]},{"Name":"1821","Title":"ConfirmApproved","DataField":"ConfirmApproved","Type":"FormFieldPart","Children":[]}]},{"Name":"HCPReferral","Title":"HCPReferral","ParentID":20,"ApiTypeID":"HCP Enrol","ServiceBody":"

Refer a patient to the MyeCare Program

Please note that all fields marked with an * are mandatory.

Enter the patient details

\n","SubmitButtonLabel":"Submit your patient referral","ServiceSuccessMsg":"

You have successfully referred a patient!

You have successfully referred your patient into the MyeCare Patient Support Programme.

The MyeCare team will now contact your patient to complete their enrolment and provide them with access to the MyeCare tools and resources.

If you have any questions about the programme, please contact the MyeCare team at either support@myecare.com or call 0800 XXX XXX.

\n","Type":"EnrolService","Children":[{"Name":"1257","Title":"TreatmentName","DataField":"TreatmentName","Type":"FormFieldPart","Children":[]},{"Name":"1725","Title":"ConfirmApproved","DataField":"ConfirmApproved","ColumnWidth":6,"Type":"FormFieldPart","Children":[]},{"Name":"1727","Title":"INCEPTUANumber","ColumnWidth":6,"AltLabel":"INCEPTUA number\nⓘ","DataField":"INCEPTUANumber","ParentID":939,"Type":"FormFieldPart","Children":[]},{"Name":"1852","Title":null,"Content":"

Patient details

\n","Type":"FormContentBlock","Children":[]},{"Name":"1190","Title":"FirstName","ColumnWidth":6,"DataField":"FirstName","AltLabel":"Patient's first name","Placeholder":"Enter their first name","Type":"FormFieldPart","Children":[]},{"Name":"1191","Title":"LastName","ColumnWidth":6,"DataField":"LastName","AltLabel":"Patient's last name","Placeholder":"Enter their last name","Type":"FormFieldPart","Children":[]},{"Name":"1193","Title":"Email","ColumnWidth":6,"DataField":"Email","AltLabel":"Patient's email address","Placeholder":"Enter their email address","Type":"FormFieldPart","Children":[]},{"Name":"1259","Title":"MobilePhone","ColumnWidth":6,"DataField":"MobilePhone","AltLabel":"Patient's mobile number","Placeholder":"Enter their mobile number","Type":"FormFieldPart","Children":[]},{"Name":"1722","Title":"DateOfBirth","HideLabel":false,"AltLabel":"Date of Birth","Readonly":false,"RequiredMessage":"This is a required field","DataField":"DateOfBirth","ColumnWidth":6,"Type":"FormFieldPart","Children":[]},{"Name":"1851","Title":"InfusionDate1","DataField":"InfusionDate1","ColumnWidth":6,"AltLabel":"Scheduled infusion date (dd/mm/yyyy) ⓘ","RequiredMessage":"This is a required field","Placeholder":"dd/mm/yyyy","Type":"FormFieldPart","Children":[]},{"Name":"1741","Title":"CarerPrimaryContact","DataField":"CarerPrimaryContact","ToggleFields":"CarerLastName,CarerFirstName,CarerRelationship,CarerEmailAddress,CarerMobilePhone","ToggleValues":"on","Header":"

Carer / guardian details (optional)

\n","Type":"FormFieldPart","Children":[]},{"Name":"1261","Title":"CarerRelationship","DataField":"CarerRelationship","AltLabel":"Carer's relationship to the patient","Placeholder":"Select their relationship to the patient","Type":"FormFieldPart","Children":[]},{"Name":"1262","Title":"CarerFirstName","ColumnWidth":6,"DataField":"CarerFirstName","Placeholder":"Enter their first name","Type":"FormFieldPart","Children":[]},{"Name":"1263","Title":"CarerLastName","ColumnWidth":6,"DataField":"CarerLastName","Placeholder":"Enter their last name","Type":"FormFieldPart","Children":[]},{"Name":"1264","Title":"CarerEmailAddress","ColumnWidth":6,"DataField":"CarerEmailAddress","Placeholder":"Enter their email address","Type":"FormFieldPart","Children":[]},{"Name":"1266","Title":"CarerMobilePhone","ColumnWidth":6,"DataField":"CarerMobilePhone","Placeholder":"Enter their mobile number","Type":"FormFieldPart","Children":[]},{"Name":"1823","Title":null,"Content":"

Prescriber/HCP details

\n","Type":"FormContentBlock","Children":[]},{"Name":"1297","Title":"PrescriberFirstName","ColumnWidth":6,"DataField":"PrescriberFirstName","ParentID":939,"Placeholder":"Enter first name","Type":"FormFieldPart","Children":[]},{"Name":"1298","Title":"PrescriberLastName","ColumnWidth":6,"DataField":"PrescriberLastName","Placeholder":"Enter last name","Type":"FormFieldPart","Children":[]},{"Name":"1299","Title":"PrescriberEmail","ColumnWidth":6,"DataField":"PrescriberEmail","Placeholder":"Enter email address","Type":"FormFieldPart","Children":[]},{"Name":"1304","Title":"PrescriberMobile","ColumnWidth":6,"HideLabel":false,"Readonly":false,"DataField":"PrescriberMobile","Placeholder":"Enter mobile number","Type":"FormFieldPart","Children":[]},{"Name":"1300","Title":"PrescriberPracticeName","ColumnWidth":6,"HideLabel":false,"Readonly":false,"DataField":"PrescriberPracticeName","AltLabel":"Your clinic / hospital name","Placeholder":"Enter the clinic / hospital name","Type":"FormFieldPart","Children":[]},{"Name":"1309","Title":"PrescriberPracticePostcode","ColumnWidth":6,"DataField":"PrescriberPracticePostcode","AltLabel":"Your clinic / hospital postcode","ParentID":939,"Placeholder":"Enter the clinic / hospital's postcode","Type":"FormFieldPart","Children":[]},{"Name":"1752","Title":"PrescriberState","DataField":"PrescriberState","AltLabel":"Your clinic / hospital state","ParentID":939,"Placeholder":"Select the clinic / hospital's state","Type":"FormFieldPart","Children":[]},{"Name":"1862","Title":null,"Content":"

Add delegate emails (optional)

Add delegate emails (optional) for any other HCP that will require access to the eye test results for review or filing purposes.

\n","Type":"FormContentBlock","Children":[]},{"Name":"1869","Title":"Delegate1First","ColumnWidth":6,"DataField":"Delegate1First","ParentID":939,"Placeholder":"Enter the first delegate's first name","Type":"FormFieldPart","Children":[]},{"Name":"1870","Title":"Delegate1Last","ColumnWidth":6,"DataField":"Delegate1Last","Placeholder":"Enter the first delegate's last name","Type":"FormFieldPart","Children":[]},{"Name":"1871","Title":"Delegate1Email","DataField":"Delegate1Email","Placeholder":"Enter the first delegate's email","Type":"FormFieldPart","Children":[]},{"Name":"1872","Title":"Delegate2First","ColumnWidth":6,"DataField":"Delegate2First","Placeholder":"Enter the second delegate's first name","Type":"FormFieldPart","Children":[]},{"Name":"1873","Title":"Delegate2Last","ColumnWidth":6,"DataField":"Delegate2Last","Placeholder":"Enter the second delegate's last name","Type":"FormFieldPart","Children":[]},{"Name":"1874","Title":"Delegate2Email","DataField":"Delegate2Email","Placeholder":"Enter the second delegate's email","Type":"FormFieldPart","Children":[]},{"Name":"1738","Title":"ConfirmPrescriber","DataField":"ConfirmPrescriber","Header":"
\n","Type":"FormFieldPart","Children":[]},{"Name":"1736","Title":"ConfirmPrescribed","DataField":"ConfirmPrescribed","Type":"FormFieldPart","Children":[]},{"Name":"1739","Title":"PatientConsentProvided","DataField":"PatientConsentProvided","Type":"FormFieldPart","Children":[]},{"Name":"1824","Title":"","Content":"

Upon receiving the patient referral, the MyeCare team will attempt to contact the patient via email and\ntelephone if required to complete the enrolment process.

\n","ParentID":939,"Type":"FormContentBlock","Children":[]}]},{"Name":"HCPEnrolmentCompletion","Title":"HCPEnrolmentCompletion","MainTitle":" Patient Access Program","ParentID":20,"ApiTypeID":"myecareReferralCompletion","SubmitButtonLabel":"Submit","ServiceSuccessMsg":"

You have successfully enrolled!

You have successfully enrolled into the MyeCare Patient Support Program.

You will soon receive a call from one of the MyeCare Program team coordinators to give you an overview of the program.

\n","ServiceBody":"

Your doctor has referred you

Please check the details provided by your doctor to ensure they are correct. If you have any questions about MyeCare, please call the MyeCare Program team on 1800 140 272, Monday to Friday 9am - 5pm (AEST).

If the details are correct, please consent to the program Terms and Conditions and Privacy Notice and submit the form.

\n","Type":"BookingService","Children":[{"Name":"1131","Title":"FirstName","ColumnWidth":6,"DataField":"FirstName","Readonly":true,"Type":"FormFieldPart","Children":[]},{"Name":"1132","Title":"LastName","ColumnWidth":6,"DataField":"LastName","Readonly":true,"Type":"FormFieldPart","Children":[]},{"Name":"1134","Title":"DateOfBirth","ColumnWidth":6,"DataField":"DateOfBirth","Readonly":true,"Type":"FormFieldPart","Children":[]},{"Name":"1764","Title":"MobilePhone","DataField":"MobilePhone","Readonly":true,"ColumnWidth":6,"Type":"FormFieldPart","Children":[]},{"Name":"1133","Title":"Email","ColumnWidth":6,"DataField":"Email","Readonly":true,"Type":"FormFieldPart","Children":[]},{"Name":"1855","Title":null,"Content":"

Your carer / guardian details (optional)

\n","Type":"FormContentBlock","Children":[]},{"Name":"1766","Title":"CarerRelationship","DataField":"CarerRelationship","Readonly":true,"Type":"FormFieldPart","Children":[]},{"Name":"1767","Title":"CarerFirstName","DataField":"CarerFirstName","Readonly":true,"ColumnWidth":6,"Type":"FormFieldPart","Children":[]},{"Name":"1768","Title":"CarerLastName","DataField":"CarerLastName","Readonly":true,"ColumnWidth":6,"Type":"FormFieldPart","Children":[]},{"Name":"1769","Title":"CarerEmailAddress","DataField":"CarerEmailAddress","Readonly":true,"ColumnWidth":6,"Type":"FormFieldPart","Children":[]},{"Name":"1770","Title":"CarerMobilePhone","DataField":"CarerMobilePhone","Readonly":true,"ColumnWidth":6,"Type":"FormFieldPart","Children":[]},{"Name":"1856","Title":null,"Content":"

Your prescriber / HCP details

\n","BlockClass":"","ContentCol2":"","ContentCol3":"","Columns":"","ImageClass":"","Image":"","Link":"","Metadata":"","Type":"FormContentBlock","Children":[]},{"Name":"1771","Title":"PrescriberFirstName","ColumnWidth":6,"HideLabel":false,"Readonly":true,"DataField":"PrescriberFirstName","AltLabel":"Your prescriber / HCP first name","Type":"FormFieldPart","Children":[]},{"Name":"1772","Title":"PrescriberLastName","DataField":"PrescriberLastName","Readonly":true,"ColumnWidth":6,"AltLabel":"Your prescriber / HCP last name","Type":"FormFieldPart","Children":[]},{"Name":"1775","Title":"PrescriberPracticeName","DataField":"PrescriberPracticeName","Readonly":true,"AltLabel":"Hospital name","ColumnWidth":6,"Type":"FormFieldPart","Children":[]},{"Name":"1777","Title":"PrescriberPracticePostcode","DataField":"PrescriberPracticePostcode","Readonly":true,"AltLabel":"Hospital postcode","ColumnWidth":6,"Type":"FormFieldPart","Children":[]},{"Name":"1778","Title":"PrescriberState","DataField":"PrescriberState","Readonly":true,"AltLabel":"Hospital state","ColumnWidth":6,"Type":"FormFieldPart","Children":[]},{"Name":"1780","Title":"PatientConfirmPrescribed","DataField":"PatientConfirmPrescribed","Type":"FormFieldPart","Children":[]},{"Name":"1782","Title":"PatientAcceptsTCsAndPrivacyPolicy","DataField":"PatientAcceptsTCsAndPrivacyPolicy","Type":"FormFieldPart","Children":[]}]},{"Name":"TestService","Title":"TestService","ServiceBody":"

This is a test service for Abishek

\n","SubmitButtonLabel":"Test me!","ParentID":20,"ApiTypeID":"TestForm","Type":"EnrolService","Children":[{"Name":"1898","Title":"FutureDateTest","AltLabel":"test future date","DataField":"FutureDateTest","Type":"FormFieldPart","Children":[]},{"Name":"1902","Title":"TestField","DataField":"TestField","AltLabel":"Test field","Type":"FormFieldPart","Children":[]}]},{"Name":"Eye Test Submot","Title":"Eye Test Submot","Type":"BookingService","Children":[]},{"Name":"HCPEnrolService","Title":"HCPEnrolService","MainTitle":"Register as an HCP for MyeCare and refer patients","ServiceSuccessMsg":"

You have successfully enrolled!

You have successfully enrolled into the wegovycare^® patient support program. You now have access to a range of services provided to support you while on your Wegovy^® (semaglutide) treatment.

Go to the homepage by clicking the “Get started” button below.

\n","SubmitButtonLabel":"Submit registration","ApiTypeID":"Phase 2 HCP Enrol","Type":"EnrolService","Children":[{"Name":"1908","Title":"PrescriberFirstName","ColumnWidth":6,"HideLabel":false,"Readonly":false,"DataField":"PrescriberFirstName","RequiredMessage":"This is a required field","Type":"FormFieldPart","Children":[]},{"Name":"1909","Title":"PrescriberLastName","ColumnWidth":6,"HideLabel":false,"Readonly":false,"RequiredMessage":"This is a required field","DataField":"PrescriberLastName","Type":"FormFieldPart","Children":[]},{"Name":"1910","Title":"PrescriberMobile","ColumnWidth":6,"HideLabel":false,"Readonly":false,"RequiredMessage":"This is a required field","DataField":"PrescriberMobile","Type":"FormFieldPart","Children":[]},{"Name":"1911","Title":"PrescriberEmail","ColumnWidth":6,"DataField":"PrescriberEmail","RequiredMessage":"This is a required field","Type":"FormFieldPart","Children":[]},{"Name":"1913","Title":"PrescriberPracticeName","ColumnWidth":6,"HideLabel":false,"Readonly":false,"DataField":"PrescriberPracticeName","Type":"FormFieldPart","Children":[]},{"Name":"1914","Title":"PrescriberPracticePostcode","ColumnWidth":6,"HideLabel":false,"Readonly":false,"DataField":"PrescriberPracticePostcode","Type":"FormFieldPart","Children":[]},{"Name":"1915","Title":"PrescriberState","ColumnWidth":6,"HideLabel":false,"Readonly":false,"DataField":"PrescriberState","Type":"FormFieldPart","Children":[]},{"Name":"1917","Title":"Password","ColumnWidth":6,"DataField":"Password","RequiredMessage":"This is a required field","Type":"FormFieldPart","Children":[]},{"Name":"1918","Title":"ConfirmPassword","ColumnWidth":6,"DataField":"ConfirmPassword","RequiredMessage":"This is a required field","Type":"FormFieldPart","Children":[]},{"Name":"1919","Title":"RegisteredQualifiedHCP","ColumnWidth":12,"HideLabel":false,"Readonly":false,"RequiredMessage":"This is a required field","DataField":"RegisteredQualifiedHCP","AltLabel":"I confirm that I am a registered, qualified healthcare professional prescribing Belantamab mafodotin*","Type":"FormFieldPart","Children":[]},{"Name":"1920","Title":"HCPConsentsToPrivacyPolicyTermsAndConditions","ColumnWidth":12,"HideLabel":false,"Readonly":false,"RequiredMessage":"This is a required field","AltLabel":"I agree to the program Terms & Conditions and Privacy Notice*","DataField":"HCPConsentsToPrivacyPolicyTermsAndConditions","Type":"FormFieldPart","Children":[]},{"Name":"1922","Title":"ConfirmStayUpdatedOnGSK","AltLabel":"Stay up to date with GSK’s future developments:

I would like to receive information about GSK’s products, new registrations, PBS listings, new scientific findings, upcoming educational and other events/ programs, etc. I agree to allow my personal information to be processed by GSK for the aforementioned purposes as described in the Privacy Notice, and I understand that I may withdraw my permission by contacting GSK via support@myecare.com.au.

GSK is dedicated to protecting your privacy. Registration with this Program shall be deemed as your consent to our processing of the personal information you provided for Program management relevant purposes. For more information about how we process your personal information and how you could exercise your rights, please see our Privacy Policy.","DataField":"ConfirmStayUpdatedOnGSK","Type":"FormFieldPart","Children":[]}]}]},{"Name":"Shared parts","Title":"Shared parts","ParentID":4,"Type":"SharedParts","Children":[{"Name":"22","Title":"LoginForm","Header":"

Patient Login

\n","EnrolCallToAction":"

Don't have login details? Enrol now

\n","ResetHeader":"

Forgotten password?

\n","ResetPassText":"

Let us know what your email address is and we will send you an email to reset your password.

\n","ResetCallToAction":"

Continue

\n","Body":"

If you are having problems logging on, please email support@nustart.co.nz or call 0800 111 059.

\n","Type":"LoginForm","Children":[]},{"Name":"jumbo-nav","Title":"SliderContainer","Metadata":"blue","Type":"SliderContainer","Children":[{"Name":"523","Title":"ContentBlock","Metadata":"blue","ContentCol2":"

$\"Learn$

\n","Type":"ContentBlock","Children":[]},{"Name":"524","Title":"ContentBlock","Content":"

Get self-injection support

If you need additional help with self-injection, you can book a complimentary injection training with one of our NUSTART nurses.

\n","Metadata":"purple","ContentCol2":"

$\"Self-injection$

\n","Type":"ContentBlock","Children":[]},{"Name":"526","Title":"ContentBlock","Content":"

Set & manage reminders

We can help you set up SMS reminders for taking your medication or your appointments.

\n","Metadata":"green","ContentCol2":"

$\"\"$

\n","Type":"ContentBlock","Children":[]}]}]}]

Welcome to the MyeCare patient referral portal

Healthcare Professional Login