{"id":256,"date":"2023-01-31T10:35:04","date_gmt":"2023-01-31T10:35:04","guid":{"rendered":"https:\/\/www.kapelhofbreda.nl\/goyarts\/inschrijfformulier\/"},"modified":"2023-01-31T10:40:49","modified_gmt":"2023-01-31T10:40:49","slug":"inschrijfformulier","status":"publish","type":"page","link":"https:\/\/www.kapelhofbreda.nl\/moolenbroek\/inschrijfformulier\/","title":{"rendered":"Inschrijfformulier"},"content":{"rendered":"\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f255-o1\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"255\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/moolenbroek\/wp-json\/wp\/v2\/pages\/256#wpcf7-f255-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"255\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.6\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f255-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/><input type=\"hidden\" name=\"_wpcf7cf_hidden_group_fields\" value=\"[]\" \/><input type=\"hidden\" name=\"_wpcf7cf_hidden_groups\" value=\"[]\" \/><input type=\"hidden\" name=\"_wpcf7cf_visible_groups\" value=\"[]\" \/><input type=\"hidden\" name=\"_wpcf7cf_repeaters\" value=\"[]\" \/><input type=\"hidden\" name=\"_wpcf7cf_steps\" value=\"{}\" \/><input type=\"hidden\" name=\"_wpcf7cf_options\" value=\"{&quot;form_id&quot;:255,&quot;conditions&quot;:[],&quot;settings&quot;:{&quot;animation&quot;:&quot;yes&quot;,&quot;animation_intime&quot;:200,&quot;animation_outtime&quot;:200,&quot;conditions_ui&quot;:&quot;normal&quot;,&quot;notice_dismissed&quot;:false,&quot;repeater_remove_button&quot;:&quot;bottom&quot;}}\" \/><input type=\"hidden\" name=\"_wpcf7_recaptcha_response\" value=\"\" \/>\n<\/fieldset>\n<b>Persoonsgegevens<\/b>\n<div class=\"form_item\"><div class=\"label\">Geslacht<\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"geslacht\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"geslacht\" value=\"Man\" \/><span class=\"wpcf7-list-item-label\">Man<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"geslacht\" value=\"Vrouw\" \/><span class=\"wpcf7-list-item-label\">Vrouw<\/span><\/label><\/span><\/span><\/span> <\/div><\/div>\n<div class=\"form_item\"><div class=\"label\">Achternaam*<\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"achternaam\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"achternaam\" \/><\/span> <\/div><\/div>\n<div class=\"form_item\"><div class=\"label\">Meisjesnaam<\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"meisjesnaam\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"meisjesnaam\" \/><\/span> <\/div><\/div>\n<div class=\"form_item\"><div class=\"label\">Voorletters*<\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"voorletters\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"voorletters\" \/><\/span> <\/div><\/div>\n<div class=\"form_item\"><div class=\"label\">Roepnaam*<\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"roepnaam\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"roepnaam\" \/><\/span> <\/div><\/div>\n<div class=\"form_item\"><div class=\"label\">Geboortedatum*<\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"geboortedatum\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"geboortedatum\" \/><\/span> <\/div><\/div>\n<div class=\"form_item\"><div class=\"label\">Geboorteplaats<\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"geboorteplaats\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"geboorteplaats\" \/><\/span> <\/div><\/div>\n<div class=\"form_item\"><div class=\"label\">Beroep<\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"beroep\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"beroep\" \/><\/span> <\/div><\/div>\n<div class=\"form_item\"><div class=\"label\">Burgerlijke staat<\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"burgerlijke_staat\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"burgerlijke_staat\" \/><\/span> <\/div><\/div>\n\n<b>Adresgegevens<\/b>\n<div class=\"form_item\"><div class=\"label\">Straatnaam*<\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"straatnaam\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"straatnaam\" \/><\/span> <\/div><\/div>\n<div class=\"form_item\"><div class=\"label\">Huisnummer*<\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"huisnummer\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"huisnummer\" \/><\/span> <\/div><\/div>\n<div class=\"form_item\"><div class=\"label\">Postcode*<\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"postcode\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"postcode\" \/><\/span> <\/div><\/div>\n<div class=\"form_item\"><div class=\"label\">Plaats*<\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"plaats\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"plaats\" \/><\/span> <\/div><\/div>\n<div class=\"form_item\"><div class=\"label\">Telefoon*<\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"telefoon\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"telefoon\" \/><\/span> <\/div><\/div>\n<div class=\"form_item\"><div class=\"label\">Mobiel<\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"mobiel\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"mobiel\" \/><\/span> <\/div><\/div>\n<div class=\"form_item\"><div class=\"label\">E-mailadres*<\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"email\" \/><\/span> <\/div><\/div>\n\n<b>Verzekeringsgegevens en BSN-Nummer<\/b>\n<div class=\"form_item\"><div class=\"label\">Naam zorgverzekeraar*<\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"zorgverzekeraar\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"zorgverzekeraar\" \/><\/span> <\/div><\/div>\n<div class=\"form_item\"><div class=\"label\">Verzekeringsnummer*<\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"verzekeringsnummer\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"verzekeringsnummer\" \/><\/span> <\/div><\/div>\n<div class=\"form_item\"><div class=\"label\">Verzekering begindatum*<\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"verzekering_datum\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"verzekering_datum\" \/><\/span> <\/div><\/div>\n<div class=\"form_item\"><div class=\"label\">BurgerServiceNummer*<\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"bsn\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"bsn\" \/><\/span> <\/div><\/div>\n\n<b>Gegevens vorige huisarts \/ huisarts op uw andere woonadres<\/b>\n<div class=\"form_item\"><div class=\"label\">Naam*<\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"naam_huisarts\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"naam_huisarts\" \/><\/span> <\/div><\/div>\n<div class=\"form_item\"><div class=\"label\">Adres*<\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"adres_huisarts\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"adres_huisarts\" \/><\/span> <\/div><\/div>\n<div class=\"form_item\"><div class=\"label\">Plaats*<\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"plaats_huisarts\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"plaats_huisarts\" \/><\/span> <\/div><\/div>\n<div class=\"form_item\"><div class=\"label\">Telefoon*<\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"telefoon_huisarts\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"telefoon_huisarts\" \/><\/span> <\/div><\/div>\n<div class=\"form_item\"><div class=\"label\">E-mailadres*<\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"email_huisarts\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"email_huisarts\" \/><\/span> <\/div><\/div>\n\n<b>Gegevens vorige apotheek\/apotheek op uw andere woonadres<\/b>\n<div class=\"form_item\"><div class=\"label\">Naam*<\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"naam_apotheek\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"naam_apotheek\" \/><\/span> <\/div><\/div>\n<div class=\"form_item\"><div class=\"label\">Adres*<\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"adres_apotheek\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"adres_apotheek\" \/><\/span> <\/div><\/div>\n<div class=\"form_item\"><div class=\"label\">Plaats*<\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"plaats_apotheek\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"plaats_apotheek\" \/><\/span> <\/div><\/div>\n<div class=\"form_item\"><div class=\"label\">Telefoon*<\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"telefoon_apotheek\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"telefoon_apotheek\" \/><\/span> <\/div><\/div>\n<div class=\"form_item\"><div class=\"label\">E-mailadres*<\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"email_apotheek\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"email_apotheek\" \/><\/span> <\/div><\/div>\n\n<b>Medische gegevens<\/b>\n<div class=\"form_item\"><div class=\"label\">Gebruikt u medicijnen?<\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"medicijnen\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"medicijnen\" value=\"Ja\" \/><span class=\"wpcf7-list-item-label\">Ja<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"medicijnen\" value=\"Nee\" \/><span class=\"wpcf7-list-item-label\">Nee<\/span><\/label><\/span><\/span><\/span> <\/div><\/div>\n<div data-id=\"medicijnen_ja\" data-orig_data_id=\"medicijnen_ja\" data-clear_on_hide class=\"\" data-class=\"wpcf7cf_group\">\n<div class=\"form_item\"><div class=\"label\">Welke (naam, dosering, gebruik per dag)<\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"medicijnen_welke\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"medicijnen_welke\"><\/textarea><\/span> <\/div><\/div>\n<\/div>\n<div class=\"form_item\"><div class=\"label\">Heeft u problemen met bepaalde medicijnen?<\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"medicijnen_problemen\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"medicijnen_problemen\" value=\"Ja\" \/><span class=\"wpcf7-list-item-label\">Ja<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"medicijnen_problemen\" value=\"Nee\" \/><span class=\"wpcf7-list-item-label\">Nee<\/span><\/label><\/span><\/span><\/span> <\/div><\/div>\n<div data-id=\"medicijnen_problemen_ja\" data-orig_data_id=\"medicijnen_problemen_ja\" data-clear_on_hide class=\"\" data-class=\"wpcf7cf_group\">\n<div class=\"form_item\"><div class=\"label\">Welk geneesmiddel geeft problemen en welk probleem heeft u?<\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"medicijnen_problemen_welke\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"medicijnen_problemen_welke\"><\/textarea><\/span> <\/div><\/div>\n<\/div>\n<div class=\"form_item\"><div class=\"label\">Maakt u gebruik van een weekdoseersysteem voor uw geneesmiddelen?*<\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"weekdoseersysteem\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"weekdoseersysteem\" value=\"Ja\" \/><span class=\"wpcf7-list-item-label\">Ja<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"weekdoseersysteem\" value=\"Nee\" \/><span class=\"wpcf7-list-item-label\">Nee<\/span><\/label><\/span><\/span><\/span> <\/div><\/div>\n\nHeeft u een chronische ziekte of komt deze ziekte in uw familie voor?<br>\nSuikerziekte*<br>\n<div class=\"form_item half\"><div class=\"label\">Bij u<\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"suikerziekte_zelf\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"suikerziekte_zelf\" value=\"Ja\" \/><span class=\"wpcf7-list-item-label\">Ja<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"suikerziekte_zelf\" value=\"Nee\" \/><span class=\"wpcf7-list-item-label\">Nee<\/span><\/label><\/span><\/span><\/span><\/div><\/div>\n<div class=\"form_item half\"><div class=\"label\">In uw familie<\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"suikerziekte_familie\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"suikerziekte_familie\" value=\"Ja\" \/><span class=\"wpcf7-list-item-label\">Ja<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"suikerziekte_familie\" value=\"Nee\" \/><span class=\"wpcf7-list-item-label\">Nee<\/span><\/label><\/span><\/span><\/span><\/div><\/div>\n\nHart\/vaatziekte*<br>\n<div class=\"form_item half\"><div class=\"label\">Bij u<\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"hartvaat_zelf\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"hartvaat_zelf\" value=\"Ja\" \/><span class=\"wpcf7-list-item-label\">Ja<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"hartvaat_zelf\" value=\"Nee\" \/><span class=\"wpcf7-list-item-label\">Nee<\/span><\/label><\/span><\/span><\/span><\/div><\/div>\n<div class=\"form_item half\"><div class=\"label\">In uw familie<\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"hartvaat_familie\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"hartvaat_familie\" value=\"Ja\" \/><span class=\"wpcf7-list-item-label\">Ja<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"hartvaat_familie\" value=\"Nee\" \/><span class=\"wpcf7-list-item-label\">Nee<\/span><\/label><\/span><\/span><\/span><\/div><\/div>\n\nNierziekte*<br>\n<div class=\"form_item half\"><div class=\"label\">Bij u<\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"nierziekte_zelf\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"nierziekte_zelf\" value=\"Ja\" \/><span class=\"wpcf7-list-item-label\">Ja<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"nierziekte_zelf\" value=\"Nee\" \/><span class=\"wpcf7-list-item-label\">Nee<\/span><\/label><\/span><\/span><\/span><\/div><\/div>\n<div class=\"form_item half\"><div class=\"label\">In uw familie<\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"nierziekte_familie\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"nierziekte_familie\" value=\"Ja\" \/><span class=\"wpcf7-list-item-label\">Ja<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"nierziekte_familie\" value=\"Nee\" \/><span class=\"wpcf7-list-item-label\">Nee<\/span><\/label><\/span><\/span><\/span><\/div><\/div>\n\nHoge bloeddruk*<br>\n<div class=\"form_item half\"><div class=\"label\">Bij u<\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"bloeddruk_zelf\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"bloeddruk_zelf\" value=\"Ja\" \/><span class=\"wpcf7-list-item-label\">Ja<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"bloeddruk_zelf\" value=\"Nee\" \/><span class=\"wpcf7-list-item-label\">Nee<\/span><\/label><\/span><\/span><\/span><\/div><\/div>\n<div class=\"form_item half\"><div class=\"label\">In uw familie<\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"bloeddruk_familie\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"bloeddruk_familie\" value=\"Ja\" \/><span class=\"wpcf7-list-item-label\">Ja<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"bloeddruk_familie\" value=\"Nee\" \/><span class=\"wpcf7-list-item-label\">Nee<\/span><\/label><\/span><\/span><\/span><\/div><\/div>\n\nAstma of COPD*<br>\n<div class=\"form_item half\"><div class=\"label\">Bij u<\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"copd_zelf\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"copd_zelf\" value=\"Ja\" \/><span class=\"wpcf7-list-item-label\">Ja<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"copd_zelf\" value=\"Nee\" \/><span class=\"wpcf7-list-item-label\">Nee<\/span><\/label><\/span><\/span><\/span><\/div><\/div>\n<div class=\"form_item half\"><div class=\"label\">In uw familie<\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"copd_familie\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"copd_familie\" value=\"Ja\" \/><span class=\"wpcf7-list-item-label\">Ja<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"copd_familie\" value=\"Nee\" \/><span class=\"wpcf7-list-item-label\">Nee<\/span><\/label><\/span><\/span><\/span><\/div><\/div>\n\nEpilepsie*<br>\n<div class=\"form_item half\"><div class=\"label\">Bij u<\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"epilepsie_zelf\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"epilepsie_zelf\" value=\"Ja\" \/><span class=\"wpcf7-list-item-label\">Ja<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"epilepsie_zelf\" value=\"Nee\" \/><span class=\"wpcf7-list-item-label\">Nee<\/span><\/label><\/span><\/span><\/span><\/div><\/div>\n<div class=\"form_item half\"><div class=\"label\">In uw familie<\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"epilepsie_familie\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"epilepsie_familie\" value=\"Ja\" \/><span class=\"wpcf7-list-item-label\">Ja<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"epilepsie_familie\" value=\"Nee\" \/><span class=\"wpcf7-list-item-label\">Nee<\/span><\/label><\/span><\/span><\/span><\/div><\/div>\n\nAndere ziekten*<br>\n<div class=\"form_item\"><div class=\"label\">Bij u<\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"andereziekte_zelf\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"andereziekte_zelf\" value=\"Ja\" \/><span class=\"wpcf7-list-item-label\">Ja<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"andereziekte_zelf\" value=\"Nee\" \/><span class=\"wpcf7-list-item-label\">Nee<\/span><\/label><\/span><\/span><\/span><\/div><\/div>\n<div data-id=\"ziekten_ja\" data-orig_data_id=\"ziekten_ja\" data-clear_on_hide class=\"\" data-class=\"wpcf7cf_group\">\n<div class=\"form_item\"><div class=\"label\">Welke<\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"andere_ziekten_welke_zelf\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"andere_ziekten_welke_zelf\"><\/textarea><\/span> <\/div><\/div>\n<\/div>\n<div class=\"form_item\"><div class=\"label\">In uw familie<\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"andere_ziekten_familie\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"andere_ziekten_familie\" value=\"Ja\" \/><span class=\"wpcf7-list-item-label\">Ja<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"andere_ziekten_familie\" value=\"Nee\" \/><span class=\"wpcf7-list-item-label\">Nee<\/span><\/label><\/span><\/span><\/span><\/div><\/div>\n<div data-id=\"ziekten_fam_ja\" data-orig_data_id=\"ziekten_fam_ja\" data-clear_on_hide class=\"\" data-class=\"wpcf7cf_group\">\n<div class=\"form_item\"><div class=\"label\">Welke<\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"andere_ziekten_welke_familie\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"andere_ziekten_welke_familie\"><\/textarea><\/span> <\/div><\/div>\n<\/div>\n\n<div class=\"form_item\"><div class=\"label\">Krijgt u een griepvaccinatie<\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"griep\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"griep\" value=\"Ja\" \/><span class=\"wpcf7-list-item-label\">Ja<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"griep\" value=\"Nee\" \/><span class=\"wpcf7-list-item-label\">Nee<\/span><\/label><\/span><\/span><\/span><\/div><\/div>\n<div data-id=\"vacc_ja\" data-orig_data_id=\"vacc_ja\" data-clear_on_hide class=\"\" data-class=\"wpcf7cf_group\">\n<div class=\"form_item\"><div class=\"label\">Waarom?<\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"vaccinatie_waarom\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"vaccinatie_waarom\"><\/textarea><\/span> <\/div><\/div>\n<\/div>\n\n<div class=\"form_item\"><div class=\"label\">Bent u onder behandeling van een specialist?<\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"specialist\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"specialist\" value=\"Ja\" \/><span class=\"wpcf7-list-item-label\">Ja<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"specialist\" value=\"Nee\" \/><span class=\"wpcf7-list-item-label\">Nee<\/span><\/label><\/span><\/span><\/span><\/div><\/div>\n<div data-id=\"specialist_ja\" data-orig_data_id=\"specialist_ja\" data-clear_on_hide class=\"\" data-class=\"wpcf7cf_group\">\n<div class=\"form_item\"><div class=\"label\">Bij wie \/ welk ziekenhuis?<\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"specialist_welke\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"specialist_welke\"><\/textarea><\/span> <\/div><\/div>\n<\/div>\n\n<div class=\"form_item\"><div class=\"label\">Bent u wel eens geopereerd?<\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"geopereerd\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"geopereerd\" value=\"Ja\" \/><span class=\"wpcf7-list-item-label\">Ja<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"geopereerd\" value=\"Nee\" \/><span class=\"wpcf7-list-item-label\">Nee<\/span><\/label><\/span><\/span><\/span><\/div><\/div>\n<div data-id=\"geopereerd_ja\" data-orig_data_id=\"geopereerd_ja\" data-clear_on_hide class=\"\" data-class=\"wpcf7cf_group\">\n<div class=\"form_item\"><div class=\"label\">Waaraan en wanneer?<\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"geopereerd_waaraan\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"geopereerd_waaraan\"><\/textarea><\/span> <\/div><\/div>\n<\/div>\n\n<div class=\"form_item\"><div class=\"label\">Heeft u ooit een ongeval gehad?<\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"ongeval\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"ongeval\" value=\"Ja\" \/><span class=\"wpcf7-list-item-label\">Ja<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"ongeval\" value=\"Nee\" \/><span class=\"wpcf7-list-item-label\">Nee<\/span><\/label><\/span><\/span><\/span><\/div><\/div>\n<div data-id=\"ongeval_ja\" data-orig_data_id=\"ongeval_ja\" data-clear_on_hide class=\"\" data-class=\"wpcf7cf_group\">\n<div class=\"form_item\"><div class=\"label\">Waaraan en wanneer?<\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"ongeval_wanneer\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"ongeval_wanneer\"><\/textarea><\/span> <\/div><\/div>\n<\/div>\n\n<div class=\"form_item\"><div class=\"label\">Zijn er onderwerpen waarvan u vindt dat de huisarts ervan op de hoogte moet zijn. Hieronder kunt u deze onderwerpen aangeven<\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"onderwerpen\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"onderwerpen\"><\/textarea><\/span><\/div><\/div>\n\n<b>Leefstijl<\/b>\n<div class=\"form_item\"><div class=\"label\">Rookt u?<\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"roken\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"roken\" value=\"Ja\" \/><span class=\"wpcf7-list-item-label\">Ja<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"roken\" value=\"Nee\" \/><span class=\"wpcf7-list-item-label\">Nee<\/span><\/label><\/span><\/span><\/span><\/div><\/div>\n<div data-id=\"roken_ja\" data-orig_data_id=\"roken_ja\" data-clear_on_hide class=\"\" data-class=\"wpcf7cf_group\">\n<div class=\"form_item\"><div class=\"label\">Hoeveel sigaren\/ sigaretten per dag?<\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"roken_hoeveel\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"roken_hoeveel\"><\/textarea><\/span> <\/div><\/div>\n<\/div>\n\n<div class=\"form_item\"><div class=\"label\">Gebruikt u alcohol?<\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"alcohol\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"alcohol\" value=\"Ja\" \/><span class=\"wpcf7-list-item-label\">Ja<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"alcohol\" value=\"Nee\" \/><span class=\"wpcf7-list-item-label\">Nee<\/span><\/label><\/span><\/span><\/span><\/div><\/div>\n<div data-id=\"alcohol_ja\" data-orig_data_id=\"alcohol_ja\" data-clear_on_hide class=\"\" data-class=\"wpcf7cf_group\">\n<div class=\"form_item\"><div class=\"label\">Hoeveel consumpties per dag\/ per week?<\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"alcohol_hoeveel\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"alcohol_hoeveel\"><\/textarea><\/span> <\/div><\/div>\n<\/div>\n\n<div class=\"form_item\"><div class=\"label\">Gebruikt u drugs?<\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"drugs\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"drugs\" value=\"Ja\" \/><span class=\"wpcf7-list-item-label\">Ja<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"drugs\" value=\"Nee\" \/><span class=\"wpcf7-list-item-label\">Nee<\/span><\/label><\/span><\/span><\/span><\/div><\/div>\n<div data-id=\"drugs_ja\" data-orig_data_id=\"drugs_ja\" data-clear_on_hide class=\"\" data-class=\"wpcf7cf_group\">\n<div class=\"form_item\"><div class=\"label\">Welke?<\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"drugs_welke\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"drugs_welke\"><\/textarea><\/span> <\/div><\/div>\n<\/div>\n\n<b>Toestemming van de pati\u00ebnt voor het opvragen en uitwisselen van gegevens<\/b>\n<div class=\"form_item\"><div class=\"label\">Medicatiegegevens bij vorige apotheek opvragen<\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"apotheek_opvragen\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"apotheek_opvragen\" value=\"Ja\" \/><span class=\"wpcf7-list-item-label\">Ja<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"apotheek_opvragen\" value=\"Nee\" \/><span class=\"wpcf7-list-item-label\">Nee<\/span><\/label><\/span><\/span><\/span><\/div><\/div>\n<div class=\"form_item\"><div class=\"label\">Gegevens uitwisselen met het ziekenhuis in het kader van een behandeling<\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"uitwisselen_ziekenhuis\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"uitwisselen_ziekenhuis\" value=\"Ja\" \/><span class=\"wpcf7-list-item-label\">Ja<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"uitwisselen_ziekenhuis\" value=\"Nee\" \/><span class=\"wpcf7-list-item-label\">Nee<\/span><\/label><\/span><\/span><\/span><\/div><\/div>\n<div class=\"form_item\"><div class=\"label\">Gegevens bij andere zorgverleners opvragen<\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"opvragen_zorgverleners\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"opvragen_zorgverleners\" value=\"Nee, nooit\" \/><span class=\"wpcf7-list-item-label\">Nee, nooit<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"opvragen_zorgverleners\" value=\"Nee, tenzij\" \/><span class=\"wpcf7-list-item-label\">Nee, tenzij<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"opvragen_zorgverleners\" value=\"Ja, altijd, geen bezwaar tegen uitwisseling\" \/><span class=\"wpcf7-list-item-label\">Ja, altijd, geen bezwaar tegen uitwisseling<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"opvragen_zorgverleners\" value=\"Ja, onder voorbehoud\" \/><span class=\"wpcf7-list-item-label\">Ja, onder voorbehoud<\/span><\/label><\/span><\/span><\/span><\/div><\/div>\n<div data-id=\"opvragen_zorgverleners_tenzij\" data-orig_data_id=\"opvragen_zorgverleners_tenzij\" data-clear_on_hide class=\"\" data-class=\"wpcf7cf_group\">\n<div class=\"form_item\"><div class=\"label\">Tenzij?<\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"opvragen_zorgverl_tenzij\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"opvragen_zorgverl_tenzij\"><\/textarea><\/span> <\/div><\/div>\n<\/div>\n<div class=\"form_item\"><div class=\"label\">Gegevens beschikbaar stellen aan zorgverleners<\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"beschikbaar_zorgverleners\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"beschikbaar_zorgverleners\" value=\"Nee, nooit\" \/><span class=\"wpcf7-list-item-label\">Nee, nooit<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"beschikbaar_zorgverleners\" value=\"Nee, tenzij\" \/><span class=\"wpcf7-list-item-label\">Nee, tenzij<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"beschikbaar_zorgverleners\" value=\"Ja, altijd, geen bezwaar tegen uitwisseling\" \/><span class=\"wpcf7-list-item-label\">Ja, altijd, geen bezwaar tegen uitwisseling<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"beschikbaar_zorgverleners\" value=\"Ja, onder voorbehoud\" \/><span class=\"wpcf7-list-item-label\">Ja, onder voorbehoud<\/span><\/label><\/span><\/span><\/span><\/div><\/div>\n<div data-id=\"beschikbaar_zorgverleners_tenzij\" data-orig_data_id=\"beschikbaar_zorgverleners_tenzij\" data-clear_on_hide class=\"\" data-class=\"wpcf7cf_group\">\n<div class=\"form_item\"><div class=\"label\">Tenzij?<\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"beschikbaar_zorgverl_tenzij\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"beschikbaar_zorgverl_tenzij\"><\/textarea><\/span> <\/div><\/div>\n<\/div>\n<div class=\"form_item\"><div class=\"label\">Overige opmerkingen<\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"overige_opmerkingen\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"overige_opmerkingen\"><\/textarea><\/span> <\/div><\/div>\n<div class=\"form_item\"><div class=\"label\"><\/div><div class=\"form_field\"><span class=\"wpcf7-form-control-wrap\" data-name=\"akkoord\"><span class=\"wpcf7-form-control wpcf7-acceptance\"><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"akkoord\" value=\"1\" aria-invalid=\"false\" \/><span class=\"wpcf7-list-item-label\">Ik ga akkoord met het opvragen en uitwisselen van mijn gegevens zoals hierboven is aangegeven<\/span><\/label><\/span><\/span><\/span> <\/div><\/div>\n<div class=\"form_item\"><div class=\"label\"><\/div><div class=\"form_field\"><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Verzenden\" \/> <\/div><\/div><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"footnotes":""},"class_list":["post-256","page","type-page","status-publish","hentry"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v28.1 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Inschrijfformulier - Huisartsenpraktijk Van 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