App like mach///form

I'm willing to pay $130-200 for this work. It must be done in 15 days or less. Daily updates are required. Most of the requirements are below. There may be some additional small requirement. The software's core functionality will resemble MachForm ([login to view URL]). Which will enable each client site's Admin user to drag 'n' drop elements to create the necessary forms to collect data into a database. The forms should contain validation checks and the ability of the Admin to show and hide form fields to specific users. The application will have four groups - Patient, Staff, Doctor, and Admin. Patient - can view and fill out patient's personal information only Staff - view and fill "Patient Report" and view only "Exam" and "Queue" Doctors - view and fill "Patient Report", "Exam Form" and view/reorder "Queue". Admin - create, view, fill and reorder all (where applicable) The application will consist of three tabs: "Patient Report", "Exam" and "Queue" tabs "Patient Report" tab (see attachment [login to view URL] this should give you a rough idea) Collect patient's personal information Should auto calculate age from date of birth field to be used in "Queue" view "Exam" tab (see attachment img167 & img168) Includes a series of check boxes that expand options when checked (if necessary). This will cut down on clutter. This will also apply to the complete set of ICD 9 codes (medical billing codes). Only some will be visible but all will be searchable so they can be selected as needed. This form includes an "arrival time" and "completion time" fields that can be filled by simply touching a button that fills it using the system clock (must also be editable if necessary) This form can only be altered by the Doctor that filled it out or the Admin. Must include a "Comments" field at the bottom that time stamps (date, time, and username) any authorized users comments. This enables other users to follow-up on a patient without altering the original form. Alerts can be set by a doctor to have a follow-up phone call be made on a specific date or a re-examination by another doctor on a specific date. Once these alerts are set the patient should then be moved to the Staff's patient "Queue" "Queue" Is a list of patients that have been assigned and submitted to a particular doctor via the "Patient Report". The list is a graphical representation of each patient with a picture/graphic representing the patient (infant, child, young adult, senior adult). It also will include the chief complaint (short summary of why they are seeing a Doctor) age and gender of patient. The list can be manipulated via drag 'n' drop to reorder/re-prioritize the patients Along the top right corner of the "Queue" tab should display the number of patients waiting to be seen Please keep in mind that the Staff will also have a "Queue" for follow-up phone calls to a patient as well as re-examinations which will be re-dispatched to an available doctor on that date. The Admin will also have a "Queue" but it will see the names of each doctor with the list of assigned patients underneath SproutCore should make some of the drag 'n' drop form fields and manipulations easier. I think this should be enough to get you started. Strong encryption must be used for "PHI" or personal health information (identifying info like name, Bday, sex, SSN)