Ruby's Flower Shop

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Updated	2 years ago
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This is a survey form. Please do not ask questions here.

[md-form]
[md-text label="Facility name"]

[/md-text]

[md-select label="Type of facility"]

[/md-select]

[group group-bite clear_on_hide]

[md-checkbox label="Select days of operation." display="inline"]
Mon-FriSatSun
[/md-checkbox]

[/group]

[group group-hiv-std clear_on_hide]

[md-checkbox label="Select days of operation." display="inline"]
Mon-FriSatSun
[/md-checkbox]

[md-radio label="Select class of facility." display="inline"]
PrivateGovNGOOthers
[/md-radio]

[md-checkbox label="Select available treatment." display="inline"]
PrEPPEP
[/md-checkbox]

[md-radio label="Is HIV testing available to non-locals?" display="inline"]
YesNo
[/md-radio]

[md-checkbox label="Select all available tests."]
HIVGonorrhea / ChlamydiaSyphilis (VDRL)Hepatitis B (HBsAg)Herpes
[/md-checkbox]

[md-checkbox label="Select all available vaccines."]
FluPREVENAR13PneumoHep AHep BMeningoHPVPolioJap EncephDPTTyphoid
[/md-checkbox]

[/group]

[group group-hotel clear_on_hide]

[md-radio label="Is short-time available?" display="inline"]
YesNo
[/md-radio]

[group group-short-time-yes clear_on_hide]
[md-text label="How much is 3 hrs?"]

[/md-text]

[md-text label="How much is 12 hrs?"]

[/md-text]
[/group]

[md-radio label="Is reservation accepted here?" display="inline"]
YesNo
[/md-radio]

[group group-reservation-yes clear_on_hide]
[md-text label="How to reserve a room?"]

[/md-text]
[/group]

[/group]

[group group-lying-in clear_on_hide]

[md-radio label="Is there a 24-hr service?" display="inline"]
YesNo
[/md-radio]

[md-checkbox label="Select all available offerings."]
Delivery (Paanak)Pregnancy testPre/Post Natal CareImmunizationNewborn ScreeningNewborn Hearing TestDEPO (DMPA)Family Planning/CounselingPill DispensingI.U.D. InsertionPapsmearBilateral Tubal LigationVasectomyUltrasound
[/md-checkbox]

[/group]

[group group-massage-spa clear_on_hide]

[md-checkbox label="Select all massage offerings."]
Shiatsu, Swedish & ThaiDeep TissueLight TouchPocketHot StoneAromatherapySportsTrigger PointReflexologyPrenatalCouple'sChairTwin
[/md-checkbox]

[md-checkbox label="Select all available features."]
Home & Hotel Service24-Hr ServiceAccepts Credit CardsAccepts ReservationsFree Wi-Fi
[/md-checkbox]

[/group]

[md-textarea label="Notes" help="Add notes like operating hrs, fees, landmark, etc."]

[/md-textarea]

[md-quiz help="Prove you are a human"]
Which comes first A or B?
[/md-quiz]

[md-submit][/md-submit]
[/md-form]

Ruby’s Flower Shop

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