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    {"id":451,"date":"2026-01-13T14:44:10","date_gmt":"2026-01-13T14:44:10","guid":{"rendered":"https:\/\/surgerywebtemp.org.uk\/c82009\/?page_id=451"},"modified":"2026-01-13T14:44:23","modified_gmt":"2026-01-13T14:44:23","slug":"village-dispensary","status":"publish","type":"page","link":"https:\/\/surgerywebtemp.org.uk\/c82009\/village-dispensary\/","title":{"rendered":"Village Dispensary"},"content":{"rendered":"<h2 class=\"wp-block-heading\">Market Harborough Medical Centre<\/h2>\n<p class=\"has-text-align-left\"><strong>24\/7 Medication Collection Kiosk<\/strong><\/p>\n<p><strong>We now offer the option for you to be able to collect your medication 24\/7!<\/strong><\/p>\n<p><strong>Our 24\/7 medication collection kiosk is the only available one in the town and it is now available for patients who live in the surrounding villages to Market Harborough!<\/strong><\/p>\n<p><strong>If you are eligible, please signup below.<\/strong><\/p>\n<p>&nbsp;<\/p>\n<hr \/>\n<p><em>Market Harborough Medical Centre now dispenses to the majority of villages in the Market Harborough area. If you live in one of the local villages, we can prepare your medications for you to collect from the Medical Centre Dispensary.<\/em><\/p>\n<p><em>Any profits made by the Dispensary are used to improve patient services. It is vital that patients eligible to use the dispensary support their surgery by signing up to collect their medications from both sites at Market Harborough and Husbands Bosworth.<\/em><\/p>\n<p><em>If you are unable to collect your medicines from the Dispensary because you are housebound,\u00a0we are able to deliver them straight to your door at no extra charge (terms and conditions apply). Please speak to the Dispenser for more details.<\/em><\/p>\n<p><em>The Dispensary opening times are from Monday to Friday, 8:30 \u2013 18:00 (closed on occasions for staff training).<\/em><\/p>\n<hr \/>\n<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 gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_11' style='display:none'><div id='gf_11' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Register with the village dispensary<\/h2>\n                        <\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_11' id='gform_11'  action='\/c82009\/wp-json\/wp\/v2\/pages\/451#gf_11' data-formid='11' novalidate>\n        <div id='gf_progressbar_wrapper_11' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<p class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>2<\/span><span class='gf_step_page_name'><\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_50' style='width:50%;'><span>50%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_11_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><div id='gform_fields_11' class='c-form-list gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_11_1\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='nhsuk-label gform-field-label' >Who are you completing this form for?&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><span class='nhsuk-hint' id='gfield_description_11_1'>For example, on behalf of a child or dependent<\/span><div class='ginput_container ginput_container_radio nhsuk-radios'>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_11_1_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_1' type='radio' value='Yourself'  id='choice_11_1_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_11_1\"   \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_11_1_0' id='label_11_1_0' class='gform-field-label gform-field-label--type-inline'>Yourself<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_11_1_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_1' type='radio' value='Someone else'  id='choice_11_1_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_11_1_1' id='label_11_1_1' class='gform-field-label gform-field-label--type-inline'>Someone else<\/label>\n\t\t\t<\/div><\/div><\/fieldset><fieldset id=\"field_11_3\" class=\"gfield nhsuk-form-group gfield--type-name gfield--input-type-name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='nhsuk-label gform-field-label nhsuk-label_before_complex' >What is the patient\u2019s name?&nbsp;&nbsp;<span class=\"nhsuk-tag\">Optional<\/span><\/legend><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_11_3'>\n                            \n                            <span id='input_11_3_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' class='nhsuk-input '  name='input_3.3' id='input_11_3_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_11_3_3' class='gform-field-label gform-field-label--type-sub '>First&nbsp;&nbsp;<span class=\"nhsuk-tag\">Optional<\/span><\/label>\n                                                <\/span>\n                            \n                            <span id='input_11_3_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' class='nhsuk-input '  name='input_3.6' id='input_11_3_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_11_3_6' class='gform-field-label gform-field-label--type-sub '>Last&nbsp;&nbsp;<span class=\"nhsuk-tag\">Optional<\/span><\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_11_4\" class=\"gfield nhsuk-form-group gfield--type-date gfield--input-type-date gfield--input-type-datedropdown gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='nhsuk-label gform-field-label' >What is the patient&#039;s date of birth?&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div id='input_11_4' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_11_4_2_container'><label for='input_11_4_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Day<\/label><select class=\"nhsuk-select\" name='input_4[]' id='input_11_4_2'   aria-required='true'  ><option value=''>Day<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_11_4_1_container'><label for='input_11_4_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Month<\/label><select class=\"nhsuk-select\" name='input_4[]' id='input_11_4_1'   aria-required='true'  ><option value=''>Month<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_11_4_3_container'><label for='input_11_4_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Year<\/label><select class=\"nhsuk-select\" name='input_4[]' id='input_11_4_3'   aria-required='true'  ><option value=''>Year<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/fieldset><fieldset id=\"field_11_5\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='nhsuk-label gform-field-label' >What is the patient&#039;s sex?&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div class='ginput_container ginput_container_radio nhsuk-radios'>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_11_5_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_5' type='radio' value='Male'  id='choice_11_5_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_11_5_0' id='label_11_5_0' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_11_5_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_5' type='radio' value='Female'  id='choice_11_5_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_11_5_1' id='label_11_5_1' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_11_5_2'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_5' type='radio' value='gf_other_choice'  id='choice_11_5_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_11_5_2' id='label_11_5_2' class='gform-field-label gform-field-label--type-inline'>Other<\/label><br \/><input id='input_11_5_other' class='gchoice_other_control' name='input_5_other' type='text' value='Other' aria-label='Other Choice, please specify'  disabled='disabled' \/>\n\t\t\t<\/div><\/div><\/fieldset><div id=\"field_11_6\" class=\"gfield nhsuk-form-group gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='nhsuk-label gform-field-label' for='input_11_6'>What is the patient&#039;s postcode?&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_11_6' type='text' value='' class='large nhsuk-input '     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_11_7\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='nhsuk-label gform-field-label' >What is your relationship to the patient?&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div class='ginput_container ginput_container_radio nhsuk-radios'>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_11_7_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_7' type='radio' value='Parent'  id='choice_11_7_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_11_7_0' id='label_11_7_0' class='gform-field-label gform-field-label--type-inline'>Parent<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_11_7_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_7' type='radio' value='Guardian'  id='choice_11_7_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_11_7_1' id='label_11_7_1' class='gform-field-label gform-field-label--type-inline'>Guardian<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_11_7_2'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_7' type='radio' value='Spouse'  id='choice_11_7_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_11_7_2' id='label_11_7_2' class='gform-field-label gform-field-label--type-inline'>Spouse<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_11_7_3'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_7' type='radio' value='Carer'  id='choice_11_7_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_11_7_3' id='label_11_7_3' class='gform-field-label gform-field-label--type-inline'>Carer<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_11_7_4'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_7' type='radio' value='Son'  id='choice_11_7_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_11_7_4' id='label_11_7_4' class='gform-field-label gform-field-label--type-inline'>Son<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_11_7_5'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_7' type='radio' value='Daughter'  id='choice_11_7_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_11_7_5' id='label_11_7_5' class='gform-field-label gform-field-label--type-inline'>Daughter<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_11_7_6'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_7' type='radio' value='Sibling'  id='choice_11_7_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_11_7_6' id='label_11_7_6' class='gform-field-label gform-field-label--type-inline'>Sibling<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_11_7_7'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_7' type='radio' value='gf_other_choice'  id='choice_11_7_7' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_11_7_7' id='label_11_7_7' class='gform-field-label gform-field-label--type-inline'>Other<\/label><br \/><input id='input_11_7_other' class='gchoice_other_control' name='input_7_other' type='text' value='Other' aria-label='Other Choice, please specify'  disabled='disabled' \/>\n\t\t\t<\/div><\/div><\/fieldset><fieldset id=\"field_11_8\" class=\"gfield nhsuk-form-group gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='nhsuk-label gform-field-label nhsuk-label_before_complex' >What is your name?&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><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_11_8'>\n                            \n                            <span id='input_11_8_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' class='nhsuk-input '  name='input_8.3' id='input_11_8_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_11_8_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_11_8_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' class='nhsuk-input '  name='input_8.6' id='input_11_8_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_11_8_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_11_9\" class=\"gfield nhsuk-form-group gfield--type-date gfield--input-type-date gfield--input-type-datedropdown gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='nhsuk-label gform-field-label' >What is your date of birth?&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div id='input_11_9' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_11_9_2_container'><label for='input_11_9_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Day<\/label><select class=\"nhsuk-select\" name='input_9[]' id='input_11_9_2'   aria-required='true'  ><option value=''>Day<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_11_9_1_container'><label for='input_11_9_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Month<\/label><select class=\"nhsuk-select\" name='input_9[]' id='input_11_9_1'   aria-required='true'  ><option value=''>Month<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_11_9_3_container'><label for='input_11_9_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Year<\/label><select class=\"nhsuk-select\" name='input_9[]' id='input_11_9_3'   aria-required='true'  ><option value=''>Year<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/fieldset><fieldset id=\"field_11_10\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='nhsuk-label gform-field-label' >What is your sex?&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div class='ginput_container ginput_container_radio nhsuk-radios'>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_11_10_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_10' type='radio' value='Male'  id='choice_11_10_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_11_10_0' id='label_11_10_0' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_11_10_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_10' type='radio' value='Female'  id='choice_11_10_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_11_10_1' id='label_11_10_1' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_11_10_2'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_10' type='radio' value='gf_other_choice'  id='choice_11_10_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_11_10_2' id='label_11_10_2' class='gform-field-label gform-field-label--type-inline'>Other<\/label><br \/><input id='input_11_10_other' class='gchoice_other_control' name='input_10_other' type='text' value='Other' aria-label='Other Choice, please specify'  disabled='disabled' \/>\n\t\t\t<\/div><\/div><\/fieldset><div id=\"field_11_11\" class=\"gfield nhsuk-form-group gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='nhsuk-label gform-field-label' for='input_11_11'>What is your postcode?&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_11_11' type='text' value='' class='large nhsuk-input '     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_11_12\" class=\"gfield nhsuk-form-group gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='nhsuk-label gform-field-label' for='input_11_12'>What is your phone number?&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_11_12' type='text' value='' class='large nhsuk-input '     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_11_13\" class=\"gfield nhsuk-form-group gfield--type-email gfield--input-type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='nhsuk-label gform-field-label' for='input_11_13'>What is your email address?&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_13' id='input_11_13' type='email' value='' class='large nhsuk-input '    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_11_14\" class=\"gfield nhsuk-form-group gfield--type-textarea gfield--input-type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='nhsuk-label gform-field-label' for='input_11_14'>Address:&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_14' id='input_11_14' class='textarea nhsuk-textarea  small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_11_15\" class=\"gfield nhsuk-form-group gfield--type-consent gfield--type-choice gfield--input-type-consent field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div class=\"nhsuk_checkboxes\"><legend class='nhsuk-label gform-field-label nhsuk-label_before_complex' >Consent&nbsp;&nbsp;<span class=\"nhsuk-tag\">Optional<\/span><\/legend><div class='ginput_container ginput_container_consent nhsuk-checkboxes__item'><input name='input_15.1' id='input_11_15_1' type='checkbox' class='nhsuk-checkboxes__input' value='1'    aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label nhsuk-label nhsuk-checkboxes__label\" for='input_11_15_1' >I consent to collecting my medication from the 24\/7 medication kiosk (subject to suitability)&nbsp;&nbsp;<span class=\"nhsuk-tag\">Optional<\/span><\/label><input type='hidden' name='input_15.2' value='I consent to collecting my medication from the 24\/7 medication kiosk (subject to suitability)' class='gform_hidden' \/><input type='hidden' name='input_15.3' value='1' class='gform_hidden' \/><\/div><\/div><\/fieldset><fieldset id=\"field_11_16\" class=\"gfield nhsuk-form-group gfield--type-consent gfield--type-choice gfield--input-type-consent gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div class=\"nhsuk_checkboxes\"><legend class='nhsuk-label gform-field-label nhsuk-label_before_complex' >Confirmation&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div class='ginput_container ginput_container_consent nhsuk-checkboxes__item'><input name='input_16.1' id='input_11_16_1' type='checkbox' class='nhsuk-checkboxes__input' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label nhsuk-label nhsuk-checkboxes__label\" for='input_11_16_1' >I confirm that I live outside the red area on the map and that I am eligible to collect medication from the village dispensary<\/label><input type='hidden' name='input_16.2' value='I confirm that I live outside the red area on the map and that I am eligible to collect medication from the village dispensary' class='gform_hidden' \/><input type='hidden' name='input_16.3' value='1' class='gform_hidden' \/><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_11_17' class='nhsuk-button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_11_2' class='gform_page' data-js='page-field-id-17' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_11_2' class='c-form-list gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_11_18\" class=\"gfield nhsuk-form-group gfield--type-html gfield--input-type-html gfield--width-full summaryList gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><dl class=\"nhsuk-summary-list\">{all_fields}<\/dl><\/div><\/div><\/div>\n        <div class='gform-page-footer gform_page_footer top_label'><input type='submit' id='gform_previous_button_11' class='nhsuk-button nhsuk-button--reverse gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='submit' id='gform_submit_button_11' class='nhsuk-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Submit'  \/> <input type='hidden' name='gform_ajax' value='form_id=11&amp;title=1&amp;description=&amp;tabindex=0&amp;theme=gravity-theme&amp;styles=[]&amp;hash=87c6a15db61ce85af287ba987e7a2a35' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_11' value='iframe' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_11' id='gform_theme_11' value='gravity-theme' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_11' id='gform_style_settings_11' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_11' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='11' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='GBP' 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