{
  "name": "Patient Registration Form",
  "description": "A medical patient intake form for collecting patient information, medical history, and consent.",
  "category": "Application",
  "tags": [
    "medical",
    "patient",
    "healthcare",
    "registration",
    "intake"
  ],
  "version": 2,
  "form_data": {
    "name": "Patient Registration Form",
    "heading": "Patient Registration",
    "description": "Please fill out this form completely to register as a new patient.",
    "formpages": [
      1
    ],
    "pages": [
      {
        "id": 1,
        "name": "Patient Information",
        "heading": "Patient Registration",
        "description": "Provide your personal and medical information.",
        "folder": "0",
        "pagerows": [
          1,
          2,
          3,
          4,
          5,
          6
        ],
        "rows": [
          {
            "id": 1,
            "name": "Personal Details",
            "heading": "Personal Information",
            "description": "Enter your personal details.",
            "folder": "0",
            "rowcolumns": [
              1,
              2
            ],
            "columns": [
              {
                "id": 1,
                "name": "Column 1",
                "fields": [
                  1
                ],
                "width": 6,
                "field_data": [
                  {
                    "id": 1,
                    "field_type": "inputtext",
                    "name": "Full Name",
                    "heading": "Full Name",
                    "description": "Enter your full legal name.",
                    "is_required": 1,
                    "placeholder": "John Doe"
                  }
                ]
              },
              {
                "id": 2,
                "name": "Column 2",
                "fields": [
                  2
                ],
                "width": 6,
                "field_data": [
                  {
                    "id": 2,
                    "field_type": "inputdate",
                    "name": "Date of Birth",
                    "heading": "Date of Birth",
                    "description": "Select your date of birth.",
                    "is_required": 1
                  }
                ]
              }
            ]
          },
          {
            "id": 2,
            "name": "Contact Information",
            "heading": "Contact Details",
            "description": "How can we reach you?",
            "folder": "0",
            "rowcolumns": [
              3,
              4
            ],
            "columns": [
              {
                "id": 3,
                "name": "Column 1",
                "fields": [
                  3
                ],
                "width": 6,
                "field_data": [
                  {
                    "id": 3,
                    "field_type": "inputemail",
                    "name": "Email Address",
                    "heading": "Email Address",
                    "description": "Enter your email address.",
                    "is_required": 1,
                    "placeholder": "john@example.com"
                  }
                ]
              },
              {
                "id": 4,
                "name": "Column 2",
                "fields": [
                  4
                ],
                "width": 6,
                "field_data": [
                  {
                    "id": 4,
                    "field_type": "inputtext",
                    "name": "Phone Number",
                    "heading": "Phone Number",
                    "description": "Enter your contact number.",
                    "is_required": 1,
                    "placeholder": "+1 (555) 123-4567"
                  }
                ]
              }
            ]
          },
          {
            "id": 3,
            "name": "Address",
            "heading": "Residential Address",
            "description": "Provide your current address.",
            "folder": "0",
            "rowcolumns": [
              5
            ],
            "columns": [
              {
                "id": 5,
                "name": "Column 1",
                "fields": [
                  5
                ],
                "width": 12,
                "field_data": [
                  {
                    "id": 5,
                    "field_type": "textarea",
                    "name": "Address",
                    "heading": "Full Address",
                    "description": "Enter your complete residential address.",
                    "is_required": 1,
                    "placeholder": "123 Main Street, Apt 4B, City, State, ZIP"
                  }
                ]
              }
            ]
          },
          {
            "id": 4,
            "name": "Emergency Contact",
            "heading": "Emergency Contact",
            "description": "Who should we contact in case of emergency?",
            "folder": "0",
            "rowcolumns": [
              6,
              7
            ],
            "columns": [
              {
                "id": 6,
                "name": "Column 1",
                "fields": [
                  6
                ],
                "width": 6,
                "field_data": [
                  {
                    "id": 6,
                    "field_type": "inputtext",
                    "name": "Emergency Contact Name",
                    "heading": "Emergency Contact Name",
                    "description": "Enter emergency contact name.",
                    "is_required": 1,
                    "placeholder": "Jane Doe"
                  }
                ]
              },
              {
                "id": 7,
                "name": "Column 2",
                "fields": [
                  7
                ],
                "width": 6,
                "field_data": [
                  {
                    "id": 7,
                    "field_type": "inputtext",
                    "name": "Emergency Contact Phone",
                    "heading": "Emergency Contact Phone",
                    "description": "Enter emergency contact phone number.",
                    "is_required": 1,
                    "placeholder": "+1 (555) 987-6543"
                  }
                ]
              }
            ]
          },
          {
            "id": 5,
            "name": "Medical History & Consent",
            "heading": "Medical Information",
            "description": "Provide relevant medical history.",
            "folder": "0",
            "rowcolumns": [
              8
            ],
            "columns": [
              {
                "id": 8,
                "name": "Column 1",
                "fields": [
                  8
                ],
                "width": 12,
                "field_data": [
                  {
                    "id": 8,
                    "field_type": "textarea",
                    "name": "Medical History",
                    "heading": "Medical History",
                    "description": "List any known allergies, current medications, or medical conditions.",
                    "is_required": 0,
                    "placeholder": "Allergies: None\nMedications: None\nConditions: None"
                  }
                ]
              }
            ]
          },
          {
            "id": 6,
            "name": "Medical History & Consent (continued)",
            "heading": "Medical Information",
            "description": "",
            "folder": "0",
            "rowcolumns": [
              9
            ],
            "columns": [
              {
                "id": 9,
                "name": "Column 2",
                "fields": [
                  9
                ],
                "width": 12,
                "field_data": [
                  {
                    "id": 9,
                    "field_type": "inputcheckbox",
                    "name": "Consent",
                    "heading": "I consent to medical treatment and privacy policy",
                    "description": "By checking this box, you agree to our terms.",
                    "is_required": 1,
                    "field_options": "[{\"I agree\": \"agree\"}]"
                  }
                ]
              }
            ]
          }
        ]
      }
    ],
    "user_action": {
      "type": "show_success_message",
      "message": "Thank you for registering! We have received your information and will contact you shortly.",
      "url": ""
    }
  }
}