Jira Service Management

{"xsrfToken":"3869a19a0f51e6c8a23d6ef8ddd11ddafd2dadd5_lout","branding":{"id":"2","key":"ac","name":"ACCRC Referral Portal","portalBaseUrl":"/servicedesk/customer/portal/2"},"helpCenterBranding":{"logoId":"","isLogoAvailable":false,"helpCenterTitle":"Welcome to the Virginia Tech Animal Cancer Care and Research Center Customer Portal","sharedPortalName":"ACCRC @ Virginia Tech","userInitialAnnouncementHeader":"","userInitialAnnouncementMessageWiki":"","translations":{"en-US":{"helpCenterTitle":"Welcome to the Virginia Tech Animal Cancer Care and Research Center Customer Portal","sharedPortalName":"ACCRC @ Virginia Tech","localeDisplayName":"English (United States)"}},"canEditAnnouncement":false,"siteDefaultLanguageTag":"en-US","userLanguageTag":"en-US","portalThemeColor":"#ef4b04","helpCenterTitleColor":"#ffffff","bannerMediaApiUrl":"https://api.media.atlassian.com/file/338ab786-1e2c-4a57-ba22-9afb9446689e/image?token=eyJhbGciOiJIUzI1NiJ9.eyJpc3MiOiIxZjhmZGQzOS0wYjg5LTQ0OWQtOWRkOS01NWVjZTljNTA3ODMiLCJhY2Nlc3MiOnsidXJuOmZpbGVzdG9yZTpmaWxlOjMzOGFiNzg2LTFlMmMtNGE1Ny1iYTIyLTlhZmI5NDQ2Njg5ZSI6WyJyZWFkIl19LCJleHAiOjE3MzQ4MDQwNTYsIm5iZiI6MTczNDgwMzQ1Nn0.l3VLLdvPUiehaEoCDS2F9pojDNfEs83ECxpD7btFyZI&client=1f8fdd39-0b89-449d-9dd9-55ece9c50783&height=300&mode=fit","bannerMediaApiFileId":"338ab786-1e2c-4a57-ba22-9afb9446689e","useDefaultBanner":false,"isBannerAvailable":true,"hasTopBarBeenSplit":false},"portal":{"id":"2","key":"ac","projectId":10001,"serviceDeskId":2,"name":"ACCRC Referral Portal","description":"Welcome, Please raise a referral for ACCRC using the referral form!","portalBaseUrl":"/servicedesk/customer/portal/2","onlyPortal":false,"reqTypes":[{"id":"17","name":"Ask a question","descriptionHtml":"","callToAction":"Ask a question","introHtml":"Have a question? Submit it here.","icon":10549,"iconUrl":"https://accrc.atlassian.net/rest/servicedeskapi/requesttype/icon/type/SD_REQTYPE/id/10549","groups":[6],"key":""},{"id":"19","name":"Patient Referral","descriptionHtml":"","callToAction":"Patient Referral","introHtml":"","icon":10509,"iconUrl":"https://accrc.atlassian.net/rest/servicedeskapi/requesttype/icon/type/SD_REQTYPE/id/10509","groups":[6],"key":""},{"id":"18","name":"Emailed request","descriptionHtml":"","callToAction":"Emailed request","introHtml":"Request received from your email support channel.","icon":10527,"iconUrl":"https://accrc.atlassian.net/rest/servicedeskapi/requesttype/icon/type/SD_REQTYPE/id/10527","groups":[],"key":""}],"reqGroups":[{"id":6,"name":"General"}],"orderMapping":{"6":[19,17]},"kbs":{"kbEnabled":false,"serviceDeskId":-1},"createPermission":true,"portalAnnouncement":{"portalId":2,"canEditAnnouncement":false,"canAdministerProject":false,"portalProjectKey":"AC","userLanguageHeader":"ACCRC Referral Update","userLanguageMessageWiki":"Thanks for your referral to the Virginia Tech Animal Cancer Care and Research Center.\n7/25/2024 Update: Our current wait times are;\n• Medical Oncology: 2 weeks for an initial consult.\n• Surgical Oncology: 2-3 weeks, and is continuing to accept patients that are eligible for clinical trials.\n• Radiation Oncology: 2 weeks for an initial teleconsult.","defaultLanguageHeader":"ACCRC Referral Update","defaultLanguageMessage":"Thanks for your referral to the Virginia Tech Animal Cancer Care and Research Center.\n \n7/25/2024 Update: Our current wait times are; \n \n•\tMedical Oncology: 2 weeks for an initial consult.\n \n•\tSurgical Oncology: 2-3 weeks, and is continuing to accept patients that are eligible for clinical trials.\n \n•\tRadiation Oncology: 2 weeks for an initial teleconsult.","defaultLanguageDisplayName":"English (United States)","isUsingLanguageSupport":false,"translations":{}},"canViewCreateRequestForm":true,"isProjectSimplified":false,"mediaApiUploadInformation":{"token":"eyJhbGciOiJIUzI1NiJ9.eyJpc3MiOiIxZjhmZGQzOS0wYjg5LTQ0OWQtOWRkOS01NWVjZTljNTA3ODMiLCJhY2Nlc3MiOnsidXJuOmZpbGVzdG9yZTpjb2xsZWN0aW9uOnVwbG9hZC1wcm9qZWN0LTEwMDAxIjpbInJlYWQiLCJjcmVhdGUiLCJ1cGRhdGUiXSwidXJuOmZpbGVzdG9yZTp1cGxvYWQ6KiI6WyJyZWFkIiwiY3JlYXRlIiwidXBkYXRlIl0sInVybjpmaWxlc3RvcmU6Y2h1bms6KiI6WyJyZWFkIiwiY3JlYXRlIl19LCJleHAiOjE3MzQ4MDQ2NTYsIm5iZiI6MTczNDgwMzQ1Nn0.AgrkisUA56iMSBUMVMkx1_MheQYNNb-mdkLo-aaJfr0","targetCollection":"upload-project-10001","endpointUrl":"https://api.media.atlassian.com","clientId":"1f8fdd39-0b89-449d-9dd9-55ece9c50783","tokenDurationInMins":20}},"reqCreate":{"id":19,"projectId":10001,"form":{"name":"Patient Referral","descriptionHtml":"","callToAction":"Patient Referral","intro":"","instructions":"","icon":10509,"iconUrl":"https://accrc.atlassian.net/rest/servicedeskapi/requesttype/icon/type/SD_REQTYPE/id/10509","key":""},"fields":[{"fieldType":"text","fieldId":"email","fieldConfigId":"","label":"Email confirmation to","description":"","descriptionHtml":"","required":true,"displayed":true,"presetValues":[]},{"fieldType":"attachment","jiraFieldType":"attachment","fieldId":"attachment","fieldConfigId":"","label":"Attachment","description":"Please Attach Medical Records, Lab Reports, Radiographs here","descriptionHtml":"Please Attach Medical Records, Lab Reports, Radiographs here","required":false,"displayed":true,"presetValues":[]},{"fieldType":"text","jiraFieldType":"summary","fieldId":"summary","fieldConfigId":"","label":"Summary","description":"","descriptionHtml":"","required":true,"displayed":false,"presetValues":["Portal Referral"]}],"userOrganisations":[],"canBrowseUsers":false,"requestCreateBaseUrl":"/servicedesk/customer/portal/2/create/19","requestValidateBaseUrl":"/servicedesk/customer/portal/2/validate/19","calendarParams":{"firstDay":0,"date":"2024-12-21T12:50:56-0500","useISO8601WeekNumbers":false,"dateIfFormat":"%e/%b/%y","dateTimeIfFormat":"%e/%b/%y %I:%M %p","timeFormat":"12"},"kbs":{"kbEnabled":false,"serviceDeskId":-1},"canRaiseOnBehalf":false,"canSignupCustomers":false,"canCreateAttachments":true,"attachmentRequiredField":false,"hasGroups":true,"canSubmitWithEmailAddress":false,"showRecaptcha":false,"siteKey":"","mediaApiUploadInformation":{"token":"eyJhbGciOiJIUzI1NiJ9.eyJpc3MiOiIxZjhmZGQzOS0wYjg5LTQ0OWQtOWRkOS01NWVjZTljNTA3ODMiLCJhY2Nlc3MiOnsidXJuOmZpbGVzdG9yZTpjb2xsZWN0aW9uOnVwbG9hZC1wcm9qZWN0LTEwMDAxIjpbInJlYWQiLCJjcmVhdGUiLCJ1cGRhdGUiXSwidXJuOmZpbGVzdG9yZTp1cGxvYWQ6KiI6WyJyZWFkIiwiY3JlYXRlIiwidXBkYXRlIl0sInVybjpmaWxlc3RvcmU6Y2h1bms6KiI6WyJyZWFkIiwiY3JlYXRlIl19LCJleHAiOjE3MzQ4MDQ2NTYsIm5iZiI6MTczNDgwMzQ1Nn0.AgrkisUA56iMSBUMVMkx1_MheQYNNb-mdkLo-aaJfr0","targetCollection":"upload-project-10001","endpointUrl":"https://api.media.atlassian.com","clientId":"1f8fdd39-0b89-449d-9dd9-55ece9c50783","tokenDurationInMins":20},"hasProformaForm":true,"proformaTemplateForm":{"id":1,"updated":"2022-07-15T18:51:03.061724Z","publish":{"jira":{"issueRequestTypeIds":[],"newIssueIssueTypeIds":[],"newIssueRequestTypeIds":[19],"submitOnCreate":true,"validateOnCreate":true},"portal":{"portalRequestTypeIds":[19],"submitOnCreate":true,"validateOnCreate":true}},"design":{"settings":{"templateId":1,"name":"ACCRC Referral Form","submit":{"lock":false,"pdf":false}},"layout":[{"version":1,"type":"doc","content":[{"type":"heading","attrs":{"level":1},"content":[{"type":"text","text":"Animal Cancer Care and Research Center @ Virginia Tech"}]},{"type":"layoutSection","content":[{"type":"layoutColumn","attrs":{"width":50},"content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":24},"localId":"de0871b0-bbb2-401b-9801-df0731963f8a"}},{"type":"paragraph","content":[]}]},{"type":"layoutColumn","attrs":{"width":50},"content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":39},"localId":"9262e1f1-1afc-4110-9cd8-3a4585c9c186"}}]}]},{"type":"heading","attrs":{"level":2},"content":[{"type":"text","text":"Client Information"}]},{"type":"layoutSection","content":[{"type":"layoutColumn","attrs":{"width":50},"content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":25},"localId":"336432e9-affd-4f7a-8f7a-d305ff034840"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":3},"localId":"f800c031-7b09-4286-a90a-22d4d036a5fd"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":4},"localId":"44cd7b1e-cc5f-42f6-b15a-94a0f85f6ec3"}},{"type":"paragraph","content":[]}]},{"type":"layoutColumn","attrs":{"width":50},"content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":26},"localId":"4abacc45-2e11-495f-8c01-68eb3db9f0fe"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":34},"localId":"ba127dcd-f7a5-4258-8d6d-01621588dd32"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":35},"localId":"ec02bc3f-42d6-4899-84b4-1e188ad78d29"}}]}]},{"type":"heading","attrs":{"level":2},"content":[{"type":"text","text":"Animal Information"}]},{"type":"layoutSection","content":[{"type":"layoutColumn","attrs":{"width":50},"content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":6},"localId":"1c1a721b-bcab-48ca-8cc3-da8a34acdfc6"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":5},"localId":"d753ec30-a7ca-480d-b038-fe71a1e80f01"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":28},"localId":"faea4123-7bfa-48fe-a84e-bd1a2d865364"}}]},{"type":"layoutColumn","attrs":{"width":50},"content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":7},"localId":"c4af389f-ec34-4714-926e-bc5bb3c97847"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":8},"localId":"3f41eba0-f108-44e6-b4af-ac89aafd2312"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":29},"localId":"8bf3d974-9c02-48d8-8547-d315d4a3335a"}}]}]},{"type":"heading","attrs":{"level":2},"content":[{"type":"text","text":"Referring Veterinarian Information / Clinic Information"}]},{"type":"layoutSection","content":[{"type":"layoutColumn","attrs":{"width":50},"content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":10},"localId":"75fcc795-fba6-4495-bbc7-73702b17ceb3"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":30},"localId":"ef90fc35-01c5-4fc0-ac07-e4314604b120"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":32},"localId":"fe3bd54a-19f6-4021-9722-bad7702b06cc"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":38},"localId":"0fd2e2b0-fafb-4e8a-b9cb-7ddd12ff1374"}}]},{"type":"layoutColumn","attrs":{"width":50},"content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":31},"localId":"5ba723f6-064e-4acc-9a02-e47c2aa1bbec"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":33},"localId":"6e6f0b35-becc-479d-8844-5e0d2d4c42a1"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":36},"localId":"5196665e-c39f-498e-b3ff-1fd7d81329e9"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":37},"localId":"7dba7d7d-3ea3-43e8-a7f2-fa46321e147e"}}]}]},{"type":"heading","attrs":{"level":2},"content":[{"type":"text","text":"Patient Case History"}]},{"type":"layoutSection","content":[{"type":"layoutColumn","attrs":{"width":50},"content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":41},"localId":"1fb87aa1-cd54-4668-8c88-a1df60457646"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":45},"localId":"12b3810b-72e4-44b0-b4f3-c5b7e0bf5d2f"}}]},{"type":"layoutColumn","attrs":{"width":50},"content":[{"type":"paragraph","content":[]},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":42},"localId":"d6cc8226-9a63-4e06-9c6d-abdbb7aa2d76"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":43},"localId":"dcc140a0-cad7-4b9d-b575-c23652b0bddc"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":44},"localId":"e118c890-3ec1-4a38-ae84-d5d77f65b5de"}}]}]},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":18},"localId":"783cc3d0-19ba-4f17-8cf3-9a1c7aa6b232"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":19},"localId":"ac611627-1c81-483f-8732-2a51d8410550"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":20},"localId":"ebf6a80c-747a-448d-a45f-d4b06fb14ffb"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":21},"localId":"4bb39c1e-1b5a-409b-a841-6a7d1dee22ba"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":23},"localId":"4569ee17-b43b-4be3-b6a3-1d06dc889b00"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":48},"localId":"9d7a76d9-7fd1-44ee-9075-f98cb4e4370d"}}]}],"conditions":{},"sections":{},"questions":{"8":{"type":"tl","label":"Age","description":"","validation":{"rq":false},"choices":[],"questionKey":""},"4":{"type":"te","label":"Email","description":"","validation":{"rq":false},"choices":[],"questionKey":""},"5":{"type":"cs","label":"Gender","description":"","validation":{"rq":false},"choices":[{"id":"47","label":"Male"},{"id":"48","label":"Female"}],"questionKey":""},"10":{"type":"ts","label":"Referring Veterinarian ","description":"","validation":{"rq":false},"jiraField":"customfield_10062","questionKey":""},"43":{"type":"da","label":"DHLPP Date","description":"","validation":{"rq":false},"choices":[],"questionKey":""},"32":{"type":"ts","label":"Phone Number","description":"","validation":{"rq":false},"choices":[],"questionKey":""},"25":{"type":"ts","label":"Name (First, Last)","description":"","validation":{"rq":false},"jiraField":"customfield_10059","questionKey":""},"31":{"type":"ts","label":"Clinic / Hospital","description":"","validation":{"rq":false},"jiraField":"customfield_10061","questionKey":""},"42":{"type":"da","label":"Rabies Date","description":"","validation":{"rq":false},"choices":[],"questionKey":""},"20":{"type":"pg","label":"Diagnostics and Procedures ","description":"Summaries or attach pertinent records","validation":{"rq":false},"choices":[],"questionKey":""},"38":{"type":"ts","label":"Best Time to Call?","description":"","validation":{"rq":false},"choices":[],"questionKey":""},"18":{"type":"pg","label":"Reason For Referral","description":"Include clinical trial name, if relevant","validation":{"rq":false},"choices":[],"questionKey":""},"3":{"type":"ts","label":"Phone Number","description":"","validation":{"rq":false},"choices":[],"questionKey":""},"28":{"type":"cs","label":"Reproductive Status","description":"","validation":{"rq":false},"choices":[{"id":"1","label":"Altered","other":false},{"id":"2","label":"Intact","other":false}],"questionKey":""},"45":{"type":"pg","label":"Vaccination Status","description":"List types, dates given","validation":{"rq":false},"choices":[],"questionKey":""},"34":{"type":"ts","label":"City, State","description":"","validation":{"rq":false},"choices":[],"questionKey":""},"19":{"type":"pg","label":"Medical History / Clinical Signs","description":"Skills and competencies needed","validation":{"rq":false},"choices":[],"questionKey":""},"23":{"type":"pg","label":"Other comments","description":"","validation":{"rq":false},"choices":[],"questionKey":""},"44":{"type":"da","label":"FDV Date","description":"","validation":{"rq":false},"choices":[],"questionKey":""},"33":{"type":"ts","label":"Clinic Address","description":"","validation":{"rq":false},"choices":[],"questionKey":""},"26":{"type":"ts","label":"Street Address","description":"","validation":{"rq":false},"choices":[],"questionKey":""},"37":{"type":"ts","label":"ZIP Code","description":"","validation":{"rq":false},"choices":[],"questionKey":""},"24":{"type":"cs","label":"Service Requested","description":"","validation":{"rq":false},"jiraField":"customfield_10065","questionKey":""},"35":{"type":"ts","label":"ZIP code","description":"","validation":{"rq":false},"choices":[],"questionKey":""},"48":{"type":"cm","label":"Document Checklist","description":"Please include the following documents if applicable. Drag and drop items into the attachment box at the top of the form ","validation":{"rq":true},"choices":[{"id":"1","label":"Vaccination Certificate","other":false},{"id":"2","label":"Medical Record","other":false},{"id":"3","label":"Lab Work","other":false},{"id":"4","label":"Imaging","other":false},{"id":"0","label":"Other...","other":true}],"questionKey":""},"21":{"type":"pg","label":"Current Treatments","description":"Including dosage and frequency","validation":{"rq":false},"choices":[],"questionKey":""},"6":{"type":"tl","label":"Animals Name","description":"","validation":{"rq":false},"jiraField":"customfield_10060","questionKey":""},"36":{"type":"ts","label":"City, State","description":"","validation":{"rq":false},"choices":[],"questionKey":""},"39":{"type":"cs","label":"Veterinarian Referral?","description":"","validation":{"rq":false},"choices":[{"id":"1","label":"Yes","other":false},{"id":"2","label":"No","other":false}],"questionKey":""},"30":{"type":"ts","label":"Email","description":"","validation":{"rq":false},"choices":[],"questionKey":""},"7":{"type":"ts","label":"Breed / Color","description":"","validation":{"rq":false},"choices":[],"questionKey":""},"29":{"type":"ts","label":"Weight","description":"","validation":{"rq":false},"choices":[],"questionKey":""},"41":{"type":"cs","label":"Condition of Patient","description":"","validation":{"rq":false},"choices":[{"id":"1","label":"Healthy","other":false},{"id":"2","label":"Stable","other":false},{"id":"3","label":"Critical","other":false}],"questionKey":""}}},"uuid":"76b1c9a0-b9cc-4577-b71c-89b25fb6d233"},"proforma":{"formExists":true,"formValid":true,"formTemplateData":{"id":1,"updated":"2022-07-15T18:51:03.061724Z","publish":{"jira":{"issueRequestTypeIds":[],"newIssueIssueTypeIds":[],"newIssueRequestTypeIds":[19],"submitOnCreate":true,"validateOnCreate":true},"portal":{"portalRequestTypeIds":[19],"submitOnCreate":true,"validateOnCreate":true}},"design":{"settings":{"templateId":1,"name":"ACCRC Referral Form","submit":{"lock":false,"pdf":false}},"layout":[{"version":1,"type":"doc","content":[{"type":"heading","attrs":{"level":1},"content":[{"type":"text","text":"Animal Cancer Care and Research Center @ Virginia Tech"}]},{"type":"layoutSection","content":[{"type":"layoutColumn","attrs":{"width":50},"content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":24},"localId":"de0871b0-bbb2-401b-9801-df0731963f8a"}},{"type":"paragraph","content":[]}]},{"type":"layoutColumn","attrs":{"width":50},"content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":39},"localId":"9262e1f1-1afc-4110-9cd8-3a4585c9c186"}}]}]},{"type":"heading","attrs":{"level":2},"content":[{"type":"text","text":"Client Information"}]},{"type":"layoutSection","content":[{"type":"layoutColumn","attrs":{"width":50},"content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":25},"localId":"336432e9-affd-4f7a-8f7a-d305ff034840"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":3},"localId":"f800c031-7b09-4286-a90a-22d4d036a5fd"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":4},"localId":"44cd7b1e-cc5f-42f6-b15a-94a0f85f6ec3"}},{"type":"paragraph","content":[]}]},{"type":"layoutColumn","attrs":{"width":50},"content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":26},"localId":"4abacc45-2e11-495f-8c01-68eb3db9f0fe"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":34},"localId":"ba127dcd-f7a5-4258-8d6d-01621588dd32"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":35},"localId":"ec02bc3f-42d6-4899-84b4-1e188ad78d29"}}]}]},{"type":"heading","attrs":{"level":2},"content":[{"type":"text","text":"Animal Information"}]},{"type":"layoutSection","content":[{"type":"layoutColumn","attrs":{"width":50},"content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":6},"localId":"1c1a721b-bcab-48ca-8cc3-da8a34acdfc6"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":5},"localId":"d753ec30-a7ca-480d-b038-fe71a1e80f01"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":28},"localId":"faea4123-7bfa-48fe-a84e-bd1a2d865364"}}]},{"type":"layoutColumn","attrs":{"width":50},"content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":7},"localId":"c4af389f-ec34-4714-926e-bc5bb3c97847"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":8},"localId":"3f41eba0-f108-44e6-b4af-ac89aafd2312"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":29},"localId":"8bf3d974-9c02-48d8-8547-d315d4a3335a"}}]}]},{"type":"heading","attrs":{"level":2},"content":[{"type":"text","text":"Referring Veterinarian Information / Clinic Information"}]},{"type":"layoutSection","content":[{"type":"layoutColumn","attrs":{"width":50},"content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":10},"localId":"75fcc795-fba6-4495-bbc7-73702b17ceb3"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":30},"localId":"ef90fc35-01c5-4fc0-ac07-e4314604b120"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":32},"localId":"fe3bd54a-19f6-4021-9722-bad7702b06cc"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":38},"localId":"0fd2e2b0-fafb-4e8a-b9cb-7ddd12ff1374"}}]},{"type":"layoutColumn","attrs":{"width":50},"content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":31},"localId":"5ba723f6-064e-4acc-9a02-e47c2aa1bbec"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":33},"localId":"6e6f0b35-becc-479d-8844-5e0d2d4c42a1"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":36},"localId":"5196665e-c39f-498e-b3ff-1fd7d81329e9"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":37},"localId":"7dba7d7d-3ea3-43e8-a7f2-fa46321e147e"}}]}]},{"type":"heading","attrs":{"level":2},"content":[{"type":"text","text":"Patient Case History"}]},{"type":"layoutSection","content":[{"type":"layoutColumn","attrs":{"width":50},"content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":41},"localId":"1fb87aa1-cd54-4668-8c88-a1df60457646"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":45},"localId":"12b3810b-72e4-44b0-b4f3-c5b7e0bf5d2f"}}]},{"type":"layoutColumn","attrs":{"width":50},"content":[{"type":"paragraph","content":[]},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":42},"localId":"d6cc8226-9a63-4e06-9c6d-abdbb7aa2d76"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":43},"localId":"dcc140a0-cad7-4b9d-b575-c23652b0bddc"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":44},"localId":"e118c890-3ec1-4a38-ae84-d5d77f65b5de"}}]}]},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":18},"localId":"783cc3d0-19ba-4f17-8cf3-9a1c7aa6b232"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":19},"localId":"ac611627-1c81-483f-8732-2a51d8410550"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":20},"localId":"ebf6a80c-747a-448d-a45f-d4b06fb14ffb"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":21},"localId":"4bb39c1e-1b5a-409b-a841-6a7d1dee22ba"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":23},"localId":"4569ee17-b43b-4be3-b6a3-1d06dc889b00"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":48},"localId":"9d7a76d9-7fd1-44ee-9075-f98cb4e4370d"}}]}],"conditions":{},"sections":{},"questions":{"8":{"type":"tl","label":"Age","description":"","validation":{"rq":false},"choices":[],"questionKey":""},"4":{"type":"te","label":"Email","description":"","validation":{"rq":false},"choices":[],"questionKey":""},"5":{"type":"cs","label":"Gender","description":"","validation":{"rq":false},"choices":[{"id":"47","label":"Male"},{"id":"48","label":"Female"}],"questionKey":""},"10":{"type":"ts","label":"Referring Veterinarian ","description":"","validation":{"rq":false},"jiraField":"customfield_10062","questionKey":""},"43":{"type":"da","label":"DHLPP Date","description":"","validation":{"rq":false},"choices":[],"questionKey":""},"32":{"type":"ts","label":"Phone Number","description":"","validation":{"rq":false},"choices":[],"questionKey":""},"25":{"type":"ts","label":"Name (First, Last)","description":"","validation":{"rq":false},"jiraField":"customfield_10059","questionKey":""},"31":{"type":"ts","label":"Clinic / Hospital","description":"","validation":{"rq":false},"jiraField":"customfield_10061","questionKey":""},"42":{"type":"da","label":"Rabies Date","description":"","validation":{"rq":false},"choices":[],"questionKey":""},"20":{"type":"pg","label":"Diagnostics and Procedures ","description":"Summaries or attach pertinent records","validation":{"rq":false},"choices":[],"questionKey":""},"38":{"type":"ts","label":"Best Time to Call?","description":"","validation":{"rq":false},"choices":[],"questionKey":""},"18":{"type":"pg","label":"Reason For Referral","description":"Include clinical trial name, if relevant","validation":{"rq":false},"choices":[],"questionKey":""},"3":{"type":"ts","label":"Phone Number","description":"","validation":{"rq":false},"choices":[],"questionKey":""},"28":{"type":"cs","label":"Reproductive Status","description":"","validation":{"rq":false},"choices":[{"id":"1","label":"Altered","other":false},{"id":"2","label":"Intact","other":false}],"questionKey":""},"45":{"type":"pg","label":"Vaccination Status","description":"List types, dates given","validation":{"rq":false},"choices":[],"questionKey":""},"34":{"type":"ts","label":"City, State","description":"","validation":{"rq":false},"choices":[],"questionKey":""},"19":{"type":"pg","label":"Medical History / Clinical Signs","description":"Skills and competencies needed","validation":{"rq":false},"choices":[],"questionKey":""},"23":{"type":"pg","label":"Other comments","description":"","validation":{"rq":false},"choices":[],"questionKey":""},"44":{"type":"da","label":"FDV Date","description":"","validation":{"rq":false},"choices":[],"questionKey":""},"33":{"type":"ts","label":"Clinic Address","description":"","validation":{"rq":false},"choices":[],"questionKey":""},"26":{"type":"ts","label":"Street Address","description":"","validation":{"rq":false},"choices":[],"questionKey":""},"37":{"type":"ts","label":"ZIP Code","description":"","validation":{"rq":false},"choices":[],"questionKey":""},"24":{"type":"cs","label":"Service Requested","description":"","validation":{"rq":false},"jiraField":"customfield_10065","questionKey":""},"35":{"type":"ts","label":"ZIP code","description":"","validation":{"rq":false},"choices":[],"questionKey":""},"48":{"type":"cm","label":"Document Checklist","description":"Please include the following documents if applicable. Drag and drop items into the attachment box at the top of the form ","validation":{"rq":true},"choices":[{"id":"1","label":"Vaccination Certificate","other":false},{"id":"2","label":"Medical Record","other":false},{"id":"3","label":"Lab Work","other":false},{"id":"4","label":"Imaging","other":false},{"id":"0","label":"Other...","other":true}],"questionKey":""},"21":{"type":"pg","label":"Current Treatments","description":"Including dosage and frequency","validation":{"rq":false},"choices":[],"questionKey":""},"6":{"type":"tl","label":"Animals Name","description":"","validation":{"rq":false},"jiraField":"customfield_10060","questionKey":""},"36":{"type":"ts","label":"City, State","description":"","validation":{"rq":false},"choices":[],"questionKey":""},"39":{"type":"cs","label":"Veterinarian Referral?","description":"","validation":{"rq":false},"choices":[{"id":"1","label":"Yes","other":false},{"id":"2","label":"No","other":false}],"questionKey":""},"30":{"type":"ts","label":"Email","description":"","validation":{"rq":false},"choices":[],"questionKey":""},"7":{"type":"ts","label":"Breed / Color","description":"","validation":{"rq":false},"choices":[],"questionKey":""},"29":{"type":"ts","label":"Weight","description":"","validation":{"rq":false},"choices":[],"questionKey":""},"41":{"type":"cs","label":"Condition of Patient","description":"","validation":{"rq":false},"choices":[{"id":"1","label":"Healthy","other":false},{"id":"2","label":"Stable","other":false},{"id":"3","label":"Critical","other":false}],"questionKey":""}}},"uuid":"76b1c9a0-b9cc-4577-b71c-89b25fb6d233"},"linkedJiraFields":["customfield_10060","customfield_10061","customfield_10062","customfield_10065","customfield_10059"]},"key":""},"portalWebFragments":{"headerPanels":[],"subheaderPanels":[],"footerPanels":[],"pagePanels":{"propertyPanels":[],"legacyPropertyPanels":[]}}}