Cancellation Vaccine Clinic

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2
Parent Name* This field is required.
First Name
Last Name
3
Email* This field is required.
example@example.com
4
Phone Number* This field is required.
Please enter a valid phone number.
5
How many children will be canceled?* This field is required.
6
Child {childNumber}'s Name* This field is required.
First
Last
7
{childName:first}'s Date of Birth* This field is required.
8
What is the appointment date and time?
Date
Month
Day
Year
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2
3
4
5
6
7
8
9
10
11
12
Hour
00
05
10
15
20
25
30
35
40
45
50
55
Minutes
AM
AM
PM
9
apptString
10
primaryEntry
11
ChildNumber
12
NextChildNumber
13
apptDateTime
14
After pressing Submit below you will be taken to a new form entry for child # {nextChildNumber} of {howManyChildren}
Should be Empty: