{"id":7255,"date":"2023-07-05T12:21:12","date_gmt":"2023-07-05T02:21:12","guid":{"rendered":"https:\/\/metronorth.health.qld.gov.au\/community\/?page_id=7255"},"modified":"2023-11-16T08:40:01","modified_gmt":"2023-11-15T22:40:01","slug":"consumer-eoi-form","status":"publish","type":"page","link":"https:\/\/metronorth.health.qld.gov.au\/community\/support-us\/get-involved\/consumer-eoi-form","title":{"rendered":"Partner with us &#8211; Consumer Expression of Interest Form"},"content":{"rendered":"<div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1 nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-0 fusion_builder_column_1_1 1_1 fusion-one-full fusion-column-first fusion-column-last\" style=\"--awb-bg-size:cover;\"><div class=\"fusion-column-wrapper fusion-flex-column-wrapper-legacy\"><div class=\"fusion-title title fusion-title-1 fusion-sep-none fusion-title-text fusion-title-size-one\"><h1 class=\"fusion-title-heading title-heading-left\" style=\"margin:0;\"><h1>Partner with us &#8211; Consumer Expression of Interest Form<\/h1><\/h1><\/div><div class=\"fusion-builder-row fusion-builder-row-inner fusion-row\"><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-0 fusion_builder_column_inner_1_1 1_1 fusion-one-full fusion-column-first fusion-column-last\" style=\"--awb-padding-top:2px;--awb-padding-right:20px;--awb-padding-bottom:2px;--awb-padding-left:20px;--awb-bg-color:#f1f1f1;--awb-bg-color-hover:#f1f1f1;--awb-bg-size:cover;\"><div class=\"fusion-column-wrapper fusion-flex-column-wrapper-legacy\"><script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_5' style='display:none'><div id='gf_5' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <p class='gform_description'>We are seeking consumers and carers like you to partner with us to improve the treatment and care we provide at Community and Oral Health, Metro North Health.<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_5'  action='\/community\/wp-json\/wp\/v2\/pages\/7255#gf_5' data-formid='5' novalidate>\n                        <div class='gform-body gform_body'><ul id='gform_fields_5' class='gform_fields top_label form_sublabel_above description_below validation_below'><li id=\"field_5_1\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p>Have you: <\/p>\n<ul><li>\nHad a good healthcare experience and want to give back?\n<\/li><li>\nNoticed there are opportunities for improvement?\n<\/li><li>\nHad a poor experience and want to influence change?\n<\/li>\n<\/ul>\n<p><\/p>\nTo register your interest please complete this form and a Community and Oral Health staff member will contact you to discuss ways you may be able to partner with us.\n<\/p><p>\nStaff of Community and Oral Health, Metro North Hospital and Health Service, elected officials (Local, State, Federal) and lobbyists are not eligible to join. These groups can email <a href=\"mailto:metronorthengage@health.qld.gov.au\"> MetroNorthEngage@health.qld.gov.au <\/a> for other options to engage with us.\n<\/p><p>\n<strong>Please note:<\/strong> If you have specific feedback or wish to make a complaint please go to the online Metro North feedback page\n<a href=\"https:\/\/metronorth.health.qld.gov.au\/contact-us\"> https:\/\/metronorth.health.qld.gov.au\/contact-us <\/a>\n<\/p><p>\nPlease register your interest in consumer engagement opportunities at Community and Oral Health, Metro North Health by completing the form below:\n<\/p><\/li><li id=\"field_5_4\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_5_4'>\n                            \n                            <span id='input_5_4_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_5_4_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                    <input type='text' name='input_4.3' id='input_5_4_3' value=''   aria-required='true'     \/>\n                                                <\/span>\n                            \n                            <span id='input_5_4_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_5_4_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                            <input type='text' name='input_4.6' id='input_5_4_6' value=''   aria-required='true'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/li><li id=\"field_5_7\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_7'>Telephone Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_5_7' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_8\" class=\"gfield gfield--type-email gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container_email gform-grid-row' id='input_5_8_container'>\n                                <span id='input_5_8_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <label for='input_5_8' class='gform-field-label gform-field-label--type-sub '>Enter Email<\/label>\n                                    <input class='' type='email' name='input_8' id='input_5_8' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                <\/span>\n                                <span id='input_5_8_2_container' class='ginput_right gform-grid-col gform-grid-col--size-auto'>\n                                    <label for='input_5_8_2' class='gform-field-label gform-field-label--type-sub '>Confirm Email<\/label>\n                                    <input class='' type='email' name='input_8_2' id='input_5_8_2' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                <\/span>\n                                <div class='gf_clear gf_clear_complex'><\/div>\n                            <\/div><\/li><li id=\"field_5_37\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Please select which services you are engaged with:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_5_37'>Please select all that apply<\/div><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_5_37'><li class='gchoice gchoice_5_37_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.1' type='checkbox'  value='Aboriginal and Torres Strait Islander Health Team'  id='choice_5_37_1'   aria-describedby=\"gfield_description_5_37\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_5_37_1' id='label_5_37_1' class='gform-field-label gform-field-label--type-inline'>Aboriginal and Torres Strait Islander Health Team<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_37_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.2' type='checkbox'  value='Adult Oral Health Services'  id='choice_5_37_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_37_2' id='label_5_37_2' class='gform-field-label gform-field-label--type-inline'>Adult Oral Health Services<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_37_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.3' type='checkbox'  value='Aged Care Assessment Team (ACAT)'  id='choice_5_37_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_37_3' id='label_5_37_3' class='gform-field-label gform-field-label--type-inline'>Aged Care Assessment Team (ACAT)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_37_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.4' type='checkbox'  value='Brighton Brain Injury Service'  id='choice_5_37_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_37_4' id='label_5_37_4' class='gform-field-label gform-field-label--type-inline'>Brighton Brain Injury Service<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_37_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.5' type='checkbox'  value='Brighton Interim Care Services'  id='choice_5_37_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_37_5' id='label_5_37_5' class='gform-field-label gform-field-label--type-inline'>Brighton Interim Care Services<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_37_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.6' type='checkbox'  value='Brighton Rehabilitation Services'  id='choice_5_37_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_37_6' id='label_5_37_6' class='gform-field-label gform-field-label--type-inline'>Brighton Rehabilitation Services<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_37_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.7' type='checkbox'  value='Brighton Wellness Hub'  id='choice_5_37_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_37_7' id='label_5_37_7' class='gform-field-label gform-field-label--type-inline'>Brighton Wellness Hub<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_37_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.8' type='checkbox'  value='Central Referral Services'  id='choice_5_37_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_37_8' id='label_5_37_8' class='gform-field-label gform-field-label--type-inline'>Central Referral Services<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_37_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.9' type='checkbox'  value='Children Oral Health Services'  id='choice_5_37_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_37_9' id='label_5_37_9' class='gform-field-label gform-field-label--type-inline'>Children Oral Health Services<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_37_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.11' type='checkbox'  value='Cooinda House'  id='choice_5_37_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_37_11' id='label_5_37_11' class='gform-field-label gform-field-label--type-inline'>Cooinda House<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_37_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.12' type='checkbox'  value='Community Based Rehabilitation Team (CBRT)'  id='choice_5_37_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_37_12' id='label_5_37_12' class='gform-field-label gform-field-label--type-inline'>Community Based Rehabilitation Team (CBRT)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_37_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.13' type='checkbox'  value='Community Palliative Care Team'  id='choice_5_37_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_37_13' id='label_5_37_13' class='gform-field-label gform-field-label--type-inline'>Community Palliative Care Team<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_37_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.14' type='checkbox'  value='Complex Chronic Diseases Team (CCDT)'  id='choice_5_37_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_37_14' id='label_5_37_14' class='gform-field-label gform-field-label--type-inline'>Complex Chronic Diseases Team (CCDT)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_37_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.15' type='checkbox'  value='Diabetes Services'  id='choice_5_37_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_37_15' id='label_5_37_15' class='gform-field-label gform-field-label--type-inline'>Diabetes Services<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_37_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.16' type='checkbox'  value='Gannet House'  id='choice_5_37_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_37_16' id='label_5_37_16' class='gform-field-label gform-field-label--type-inline'>Gannet House<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_37_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.17' type='checkbox'  value='Hospital in the Home (HITH)'  id='choice_5_37_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_37_17' id='label_5_37_17' class='gform-field-label gform-field-label--type-inline'>Hospital in the Home (HITH)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_37_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.18' type='checkbox'  value='Post Acute Care Services  (PACS)'  id='choice_5_37_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_37_18' id='label_5_37_18' class='gform-field-label gform-field-label--type-inline'>Post Acute Care Services  (PACS)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_37_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.19' type='checkbox'  value='Halwyn Centre'  id='choice_5_37_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_37_19' id='label_5_37_19' class='gform-field-label gform-field-label--type-inline'>Halwyn Centre<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_37_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.21' type='checkbox'  value='Wound and Stoma Team'  id='choice_5_37_21'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_37_21' id='label_5_37_21' class='gform-field-label gform-field-label--type-inline'>Wound and Stoma Team<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_37_22'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.22' type='checkbox'  value='Residential Transition Care Program - Zillmere'  id='choice_5_37_22'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_37_22' id='label_5_37_22' class='gform-field-label gform-field-label--type-inline'>Residential Transition Care Program - Zillmere<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_37_23'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.23' type='checkbox'  value='Other'  id='choice_5_37_23'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_37_23' id='label_5_37_23' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_38\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_38'>Please specify:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_38' id='input_5_38' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_33\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >How would you like to partner with us (Please select all that apply)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_5_33'><li class='gchoice gchoice_5_33_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.1' type='checkbox'  value='Invitation, involvement and \/or support at an event'  id='choice_5_33_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_33_1' id='label_5_33_1' class='gform-field-label gform-field-label--type-inline'>Invitation, involvement and \/or support at an event<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_33_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.2' type='checkbox'  value='Provide feedback (project\/topic\/literature)'  id='choice_5_33_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_33_2' id='label_5_33_2' class='gform-field-label gform-field-label--type-inline'>Provide feedback (project\/topic\/literature)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_33_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.3' type='checkbox'  value='Participate in workshop or focus group'  id='choice_5_33_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_33_3' id='label_5_33_3' class='gform-field-label gform-field-label--type-inline'>Participate in workshop or focus group<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_33_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.4' type='checkbox'  value='Participate in a committee, co-design, redesign or service improvement initiatives'  id='choice_5_33_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_33_4' id='label_5_33_4' class='gform-field-label gform-field-label--type-inline'>Participate in a committee, co-design, redesign or service improvement initiatives<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_33_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.5' type='checkbox'  value='Share my story or map my patient journey'  id='choice_5_33_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_33_5' id='label_5_33_5' class='gform-field-label gform-field-label--type-inline'>Share my story or map my patient journey<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_33_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.6' type='checkbox'  value='Present as a speaker at training or an event, or conference'  id='choice_5_33_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_33_6' id='label_5_33_6' class='gform-field-label gform-field-label--type-inline'>Present as a speaker at training or an event, or conference<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_33_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.7' type='checkbox'  value='Unsure'  id='choice_5_33_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_33_7' id='label_5_33_7' class='gform-field-label gform-field-label--type-inline'>Unsure<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_35\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_35'>Other, please specify:<\/label><div class='ginput_container ginput_container_text'><input name='input_35' id='input_5_35' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_21\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_21'>Do you have any other comments?<\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_5_21' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_14\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p><strong>Information disclaimer<\/strong><\/p>\n<p>Your personal information will be included in our database. Your details will remain confidential and will only be used for engagement activities coordinated by Community and Oral Health, Metro North Health. 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