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Sample Form: ثبت‌نام واکسیناسیون

نوع واکسن، نوبت، سابقه‌ی حساسیت و بارداری؛ برای مراکز بهداشت.

9 questions · Free up to 50 responses a month

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About this template

“ثبت‌نام واکسیناسیون” has 9 questions; 8 are required and 1 optional. Question types: Yes / No (2), Short text (1), Mobile number (1), National ID (1), Date (1), Dropdown (1), Single choice (1), Booking (1). 7 ready-made options across 2 choice questions, all editable in the online version.

In the online version of this template

  • National IDs are checked instantly with the check-digit algorithm.
  • Mobile numbers are validated against the Iranian number format.
  • Dates are picked and stored on the Jalali (Persian) calendar.
  • Appointments can only be picked from free time slots.
Related:Online form builderIranian national ID validatorBooking

Questions in this template

  1. 1.

    نام و نام خانوادگی *

    (Short text)
  2. 2.

    شماره موبایل *

    (Mobile number)
  3. 3.

    کد ملی *

    (National ID)
  4. 4.

    تاریخ تولد *

    (Date)
  5. 5.

    واکسن *

    (Dropdown)
    • آنفلوانزا
    • کووید
    • هپاتیت B
    • کزاز
  6. 6.

    نوبت *

    (Single choice)
    • اول
    • دوم
    • یادآور
  7. 7.

    سابقه‌ی واکنش شدید به واکسن؟ *

    (Yes / No)
  8. 8.

    باردار یا شیرده هستید؟

    (Yes / No)
  9. 9.

    زمان مراجعه *

    (Booking)

Printable or online?

Printable version (Word & PDF)

  • For filling in on paper, signing and filing by hand
  • Edit the Word file any way you like
  • Collecting and typing up the answers is up to you
Download WordDownload PDF

Online version on Porsino

  • Answers are collected and organised automatically — no retyping
  • National ID, mobile number and dates are validated instantly
  • Ready-made reports and charts, plus Excel export in one click
  • Share a link or QR code — it works on mobile too
Build the online version for free

How do I use this template?

  1. Sign up for Porsino for free; no bank card needed.
  2. In the panel, open “Templates” and choose “ثبت‌نام واکسیناسیون”.
  3. Change the questions as you like, publish the form and send the link.

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