{"id":2651,"date":"2024-02-01T13:42:44","date_gmt":"2024-02-01T12:42:44","guid":{"rendered":"https:\/\/043arts.nl\/?post_type=praktijkinformatie&#038;p=2651"},"modified":"2024-05-31T13:25:20","modified_gmt":"2024-05-31T11:25:20","slug":"register","status":"publish","type":"praktijkinformatie","link":"https:\/\/huisartsomdehoek.nl\/en\/praktijkinformatie\/inschrijven\/","title":{"rendered":"Subscribe"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-post\" data-elementor-id=\"2651\" class=\"elementor elementor-2651\" data-elementor-post-type=\"praktijkinformatie\">\n\t\t\t\t<div class=\"elementor-element elementor-element-3077fb4b e-flex e-con-boxed e-con e-parent\" data-id=\"3077fb4b\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;jet_parallax_layout_list&quot;:[]}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-68a7f10 elementor-widget elementor-widget-heading\" data-id=\"68a7f10\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Inschrijven<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-29583863 e-flex e-con-boxed e-con e-parent\" data-id=\"29583863\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;jet_parallax_layout_list&quot;:[]}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-4d260348 e-con-full e-flex e-con e-child\" data-id=\"4d260348\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;jet_parallax_layout_list&quot;:[]}\">\n\t\t\t\t<div class=\"elementor-element elementor-element-4a0b9127 box-shadow-backdrop elementor-widget elementor-widget-image\" data-id=\"4a0b9127\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<img fetchpriority=\"high\" decoding=\"async\" width=\"2000\" height=\"1333\" src=\"https:\/\/huisartsomdehoek.nl\/wp-content\/uploads\/2023\/02\/team.jpg\" class=\"attachment-full size-full wp-image-847\" alt=\"\" srcset=\"https:\/\/huisartsomdehoek.nl\/wp-content\/uploads\/2023\/02\/team.jpg 2000w, https:\/\/huisartsomdehoek.nl\/wp-content\/uploads\/2023\/02\/team-300x200.jpg 300w, https:\/\/huisartsomdehoek.nl\/wp-content\/uploads\/2023\/02\/team-1024x682.jpg 1024w, https:\/\/huisartsomdehoek.nl\/wp-content\/uploads\/2023\/02\/team-768x512.jpg 768w, https:\/\/huisartsomdehoek.nl\/wp-content\/uploads\/2023\/02\/team-1536x1024.jpg 1536w\" sizes=\"(max-width: 2000px) 100vw, 2000px\" \/>\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-6999473 e-con-full e-flex e-con e-child\" data-id=\"6999473\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;jet_parallax_layout_list&quot;:[]}\">\n\t\t\t\t<div class=\"elementor-element elementor-element-2139077f elementor-widget elementor-widget-heading\" data-id=\"2139077f\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Inschrijven<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-506f27a5 elementor-widget elementor-widget-text-editor\" data-id=\"506f27a5\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>Wij zijn open voor nieuwe inschrijvingen bij een woonadres met postcode 2585 EN indien u nog geen huisarts in Den Haag heeft. Vul het formulier volledig in.\u00a0<\/p><p>Heeft u nog verdere vragen? Dan kunt u een telefonische terugbelafspraak maken.\u00a0<\/p><p>Neem hiervoor contact op met onze doktersassistente.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-0fba917 elementor-widget elementor-widget-global elementor-global-2718 elementor-widget-jet-form-builder-form\" data-id=\"0fba917\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"jet-form-builder-form.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<link rel='stylesheet' id='wp-block-library-css' href='https:\/\/huisartsomdehoek.nl\/wp-includes\/css\/dist\/block-library\/style.min.css?ver=9462966632b1e973ac6ec5849fe2b9b6' media='all' \/>\n<style id=\"jet-form-builder-2701-inline-css\"><\/style><form  class=\"jet-form-builder layout-column submit-type-ajax\" action=\"https:\/\/huisartsomdehoek.nl\/en\/wp-json\/wp\/v2\/praktijkinformatie\/2651\/?H9PPSv=83gftReFFS&amp;method=reload\" method=\"POST\" data-form-id=\"2701\" data-layout=\"column\" enctype=\"multipart\/form-data\" data-clear=\"1\" novalidate=\"null\" ssr_validation_method=\"rest\">\r\n<input type=\"hidden\" name=\"_jfb_current_render_states[]\" value=\"DEFAULT.STATE\" data-jfb-sync \/><input type=\"hidden\" class=\"jet-form-builder__field hidden-field\" name=\"_jet_engine_booking_form_id\" data-field-name=\"_jet_engine_booking_form_id\" value=\"2701\">\n<input type=\"hidden\" class=\"jet-form-builder__field hidden-field\" name=\"_jet_engine_refer\" data-field-name=\"_jet_engine_refer\" value=\"https:\/\/huisartsomdehoek.nl\/en\/wp-json\/wp\/v2\/praktijkinformatie\/2651\/\">\n<input type=\"hidden\" class=\"jet-form-builder__field hidden-field\" name=\"__queried_post_id\" data-field-name=\"__queried_post_id\" value=\"2651\">\n<div class=\"jet-form-builder-progress-pages jfb-progress-type--default jet-form-builder-progress-pages--global\" data-type=\"default\">\t<div class=\"jet-form-builder-progress-pages__item--wrapper active-page\" data-page=\"1\">\n\t\t<div class=\"jet-form-builder-progress-pages__item\">\n\t\t\t<div class=\"jet-form-builder-progress-pages__item--circle\">1<\/div>\n\t\t\t<div class=\"jet-form-builder-progress-pages__item--label\"> <\/div>\n\t\t<\/div>\n\t\t\t\t\t<div class=\"jet-form-builder-progress-pages__separator\"><\/div>\n\t\t\t<\/div>\n\t\t<div class=\"jet-form-builder-progress-pages__item--wrapper\" data-page=\"2\">\n\t\t<div class=\"jet-form-builder-progress-pages__item\">\n\t\t\t<div class=\"jet-form-builder-progress-pages__item--circle\">2<\/div>\n\t\t\t<div class=\"jet-form-builder-progress-pages__item--label\"> <\/div>\n\t\t<\/div>\n\t\t\t\t\t<div class=\"jet-form-builder-progress-pages__separator\"><\/div>\n\t\t\t<\/div>\n\t\t<div class=\"jet-form-builder-progress-pages__item--wrapper\" data-page=\"3\">\n\t\t<div class=\"jet-form-builder-progress-pages__item\">\n\t\t\t<div class=\"jet-form-builder-progress-pages__item--circle\">3<\/div>\n\t\t\t<div class=\"jet-form-builder-progress-pages__item--label\"> <\/div>\n\t\t<\/div>\n\t\t\t\t\t<div class=\"jet-form-builder-progress-pages__separator\"><\/div>\n\t\t\t<\/div>\n\t\t<div class=\"jet-form-builder-progress-pages__item--wrapper\" data-page=\"4\">\n\t\t<div class=\"jet-form-builder-progress-pages__item\">\n\t\t\t<div class=\"jet-form-builder-progress-pages__item--circle\">4<\/div>\n\t\t\t<div class=\"jet-form-builder-progress-pages__item--label\">Last Page<\/div>\n\t\t<\/div>\n\t\t\t<\/div>\n\t<\/div><div class=\"jet-form-builder-page \" data-page=\"1\" data-page-offset=\"75\">\n\n\n\n\n\n<div  class=\"jet-form-builder-row field-type-text-field\" >\n<div class=\"jet-form-builder__field-wrap\">\n\t\t\t\t<input placeholder=\"Voornamen (Volledig)\" required=\"required\" name=\"voornamen\" id=\"voornamen\" type=\"text\" data-field-name=\"voornamen\" class=\"jet-form-builder__field text-field\" data-jfb-sync=\"null\" autocomplete=\"off_v8e1Kmh6\">\n\t\t\t\t\t<\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-text-field\" >\n<div class=\"jet-form-builder__field-wrap\">\n\t\t\t\t<input placeholder=\"Achternaam\" required=\"required\" name=\"achternaam\" id=\"achternaam\" type=\"text\" data-field-name=\"achternaam\" class=\"jet-form-builder__field text-field\" data-jfb-sync=\"null\" autocomplete=\"off_dCRZpruO\">\n\t\t\t\t\t<\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-select-field wp-block-jet-forms-select-field\">\n<div class=\"jet-form-builder__field-wrap\">\n\t<select class=\"jet-form-builder__field select-field\" required=\"required\" name=\"geslacht\" data-field-name=\"geslacht\" id=\"geslacht\" data-jfb-sync=\"null\">\n\t\t<option value=\"man\" >Man<\/option><option value=\"vrouw\" >Vrouw<\/option>\t<\/select>\n<\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-text-field\" >\n<div class=\"jet-form-builder__field-wrap\">\n\t\t\t\t<input placeholder=\"Geboortedatum\" required=\"required\" name=\"geboortedatum\" id=\"geboortedatum\" type=\"text\" data-field-name=\"geboortedatum\" class=\"jet-form-builder__field text-field\" data-jfb-sync=\"null\" autocomplete=\"off_6MjnfmCs\">\n\t\t\t\t\t<\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-text-field\" >\n<div class=\"jet-form-builder__field-wrap\">\n\t\t\t\t<input placeholder=\"Geboorteplaats\" required=\"required\" name=\"geboorteplaats\" id=\"geboorteplaats\" type=\"text\" data-field-name=\"geboorteplaats\" class=\"jet-form-builder__field text-field\" data-jfb-sync=\"null\" autocomplete=\"off_fltMsGdm\">\n\t\t\t\t\t<\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-text-field\" >\n<div class=\"jet-form-builder__field-wrap\">\n\t\t\t\t<input placeholder=\"E-mailadres\" required=\"required\" name=\"email\" id=\"email\" type=\"email\" data-field-name=\"email\" class=\"jet-form-builder__field text-field\" data-jfb-sync=\"null\" autocomplete=\"off_Bio3Gzfj\">\n\t\t\t\t\t<\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-text-field\" >\n<div class=\"jet-form-builder__field-wrap\">\n\t\t\t\t<input placeholder=\"Telefoonnummer\" required=\"required\" name=\"telefoonnummer\" id=\"telefoonnummer\" type=\"text\" data-field-name=\"telefoonnummer\" class=\"jet-form-builder__field text-field\" data-jfb-sync=\"null\" autocomplete=\"off_sI1CWEBM\">\n\t\t\t\t\t<\/div>\n<\/div>\n\n\n<div class=\"wp-block-jet-engine-container jet-container jet-container--content-direction-horizontal jet-container--content-align-flex-start jet-container--content-justify-flex-end wp-block-jet-engine-container\"><div class=\"jet-container__overlay   \" style=\"opacity:0.5\"><\/div><div  class=\"jet-form-builder-row field-type-submit-field\" >\n\t<div data-type=\"next\" class=\"jet-form-builder__action-button-wrapper\">\n\t<button class=\"jet-form-builder__action-button jet-form-builder__next-page\" type=\"button\" data-jfb-conditional=\"[{&quot;page_state&quot;:&quot;active&quot;}]\" data-jfb-func=\"disable\">Volgende<\/button>\n\t<\/div>\n\t\n<\/div><\/div>\n\n\n<div class=\"jet-form-builder__next-page-wrap\">\n\t\t\t<\/div>\n<\/div>\n<div class=\"jet-form-builder-page jet-form-builder-page--hidden\" data-page=\"2\" data-page-offset=\"75\">\n\n<div  class=\"jet-form-builder-row field-type-text-field\" >\n<div class=\"jet-form-builder__field-wrap\">\n\t\t\t\t<input placeholder=\"Straat\" required=\"required\" name=\"straat\" id=\"straat\" type=\"text\" data-field-name=\"straat\" class=\"jet-form-builder__field text-field\" data-jfb-sync=\"null\" autocomplete=\"off_ETJAb1UG\">\n\t\t\t\t\t<\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-text-field\" >\n<div class=\"jet-form-builder__field-wrap\">\n\t\t\t\t<input placeholder=\"Huisnummer\" required=\"required\" name=\"huisnummer\" id=\"huisnummer\" type=\"text\" data-field-name=\"huisnummer\" class=\"jet-form-builder__field text-field\" data-jfb-sync=\"null\" autocomplete=\"off_ho1BCK03\">\n\t\t\t\t\t<\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-text-field\" >\n<div class=\"jet-form-builder__field-wrap\">\n\t\t\t\t<input placeholder=\"Huisnummer Toevoeging\" required=\"required\" name=\"huisnummer_toevoeging\" id=\"huisnummer_toevoeging\" type=\"text\" data-field-name=\"huisnummer_toevoeging\" class=\"jet-form-builder__field text-field\" data-jfb-sync=\"null\" autocomplete=\"off_SucGdJZU\">\n\t\t\t\t\t<\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-text-field\" >\n<div class=\"jet-form-builder__field-wrap\">\n\t\t\t\t<input placeholder=\"Postcode\" required=\"required\" name=\"postcode\" id=\"postcode\" type=\"text\" data-field-name=\"postcode\" class=\"jet-form-builder__field text-field\" data-jfb-sync=\"null\" autocomplete=\"off_O1Ckp0ts\">\n\t\t\t\t\t<\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-text-field\" >\n<div class=\"jet-form-builder__field-wrap\">\n\t\t\t\t<input placeholder=\"Plaats\" required=\"required\" name=\"plaats\" id=\"plaats\" type=\"text\" data-field-name=\"plaats\" class=\"jet-form-builder__field text-field\" data-jfb-sync=\"null\" autocomplete=\"off_svxcZQqd\">\n\t\t\t\t\t<\/div>\n<\/div>\n\n\n<div class=\"wp-block-jet-engine-container jet-container jet-container--content-direction-horizontal jet-container--content-align-flex-start jet-container--content-justify-space-between wp-block-jet-engine-container\"><div class=\"jet-container__overlay   \" style=\"opacity:0.5\"><\/div><div  class=\"jet-form-builder-row field-type-submit-field\" >\n\t<div data-type=\"prev\" class=\"jet-form-builder__action-button-wrapper\">\n\t<button class=\"jet-form-builder__action-button jet-form-builder__prev-page\" type=\"button\">Vorige<\/button>\n\t<\/div>\n\t\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-submit-field\" >\n\t<div data-type=\"next\" class=\"jet-form-builder__action-button-wrapper\">\n\t<button class=\"jet-form-builder__action-button jet-form-builder__next-page\" type=\"button\" data-jfb-conditional=\"[{&quot;page_state&quot;:&quot;active&quot;}]\" data-jfb-func=\"disable\">Volgende<\/button>\n\t<\/div>\n\t\n<\/div><\/div>\n\n\n<div class=\"jet-form-builder__next-page-wrap\">\n\t\t\t<\/div>\n<\/div>\n<div class=\"jet-form-builder-page jet-form-builder-page--hidden\" data-page=\"3\" data-page-offset=\"75\">\n\n<div  class=\"jet-form-builder-row field-type-text-field\" >\n<div class=\"jet-form-builder__field-wrap\">\n\t\t\t\t<input placeholder=\"BSN (Burgerservicenummer)\" required=\"required\" name=\"bsn\" id=\"bsn\" type=\"text\" data-field-name=\"bsn\" class=\"jet-form-builder__field text-field\" data-jfb-sync=\"null\" autocomplete=\"off_jgiehdEx\">\n\t\t\t\t\t<\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-select-field wp-block-jet-forms-select-field\">\n<div class=\"jet-form-builder__field-wrap\">\n\t<select class=\"jet-form-builder__field select-field\" required=\"required\" name=\"id_type\" data-field-name=\"id_type\" id=\"id_type\" data-jfb-sync=\"null\">\n\t\t<option value=\"\" selected=\"selected\">Identificatie<\/option><option value=\"Paspoort\" >Paspoort<\/option><option value=\"Rijbewijs\" >Rijbewijs<\/option><option value=\"Identiteitskaart\" >Identiteitskaart<\/option><option value=\"Vreemdelingen document\" >Vreemdelingen document<\/option><option value=\"Uittreksel BRP\" >Uittreksel BRP<\/option>\t<\/select>\n<\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-text-field\" >\n<div class=\"jet-form-builder__field-wrap\">\n\t\t\t\t<input placeholder=\"Documentnummer legitimatie\" required=\"required\" name=\"id_nummer\" id=\"id_nummer\" type=\"text\" data-field-name=\"id_nummer\" class=\"jet-form-builder__field text-field\" data-jfb-sync=\"null\" autocomplete=\"off_qQCBcHAK\">\n\t\t\t\t\t<\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-text-field\" >\n<div class=\"jet-form-builder__field-wrap\">\n\t\t\t\t<input placeholder=\"Verzekering\" required=\"required\" name=\"verzekering\" id=\"verzekering\" type=\"text\" data-field-name=\"verzekering\" class=\"jet-form-builder__field text-field\" data-jfb-sync=\"null\" autocomplete=\"off_mwFKaNp0\">\n\t\t\t\t\t<\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-text-field\" >\n<div class=\"jet-form-builder__field-wrap\">\n\t\t\t\t<input placeholder=\"Polisnummer\" required=\"required\" name=\"polisnummer\" id=\"polisnummer\" type=\"text\" data-field-name=\"polisnummer\" class=\"jet-form-builder__field text-field\" data-jfb-sync=\"null\" autocomplete=\"off_7J568fEM\">\n\t\t\t\t\t<\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-text-field\" >\n<div class=\"jet-form-builder__label\">\r\n<label class=\"jet-form-builder__label-text\" for=\"apotheek\">Apotheek <span class=\"jet-form-builder__required\">*<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap\">\n\t\t\t\t<input required=\"required\" name=\"apotheek\" id=\"apotheek\" type=\"text\" data-field-name=\"apotheek\" class=\"jet-form-builder__field text-field\" data-jfb-sync=\"null\" autocomplete=\"off_kmA4rV8Q\">\n\t\t\t\t\t<\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-text-field\" >\n<div class=\"jet-form-builder__field-wrap\">\n\t\t\t\t<input placeholder=\"Vorige Huisarts\" required=\"required\" name=\"vorige_huisarts\" id=\"vorige_huisarts\" type=\"text\" data-field-name=\"vorige_huisarts\" class=\"jet-form-builder__field text-field\" data-jfb-sync=\"null\" autocomplete=\"off_5HO1ywMa\">\n\t\t\t\t\t<\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-select-field wp-block-jet-forms-select-field\">\n<div class=\"jet-form-builder__label\">\r\n<label class=\"jet-form-builder__label-text\" for=\"praktijkondersteuner\">Was u bij uw vorige huisarts onder controle van de praktijkondersteuner? <span class=\"jet-form-builder__required\">*<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap\">\n\t<select class=\"jet-form-builder__field select-field\" required=\"required\" name=\"praktijkondersteuner\" data-field-name=\"praktijkondersteuner\" id=\"praktijkondersteuner\" data-jfb-sync=\"null\">\n\t\t<option value=\"\"  selected>Selecteer een optie...<\/option><option value=\"Ja\" >Ja<\/option><option value=\"Nee\" >Nee<\/option>\t<\/select>\n<\/div>\n<\/div>\n\n<div class=\"jet-form-builder__conditional \" data-jfb-conditional=\"[{&quot;operator&quot;:&quot;equal&quot;,&quot;value&quot;:&quot;Ja&quot;,&quot;field&quot;:&quot;praktijkondersteuner&quot;,&quot;use_preset&quot;:false}]\" data-jfb-func=\"show\">\n<div  class=\"jet-form-builder-row field-type-checkbox-field\" >\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">Kunt u ook aangeven waarvoor?<\/div><\/div><div class=\"jet-form-builder__fields-group checkradio-wrap\" data-jfb-sync><div class=\"jet-form-builder__field-wrap checkboxes-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-checkbox\">\n\t\t\t<input type=\"checkbox\" name=\"waarvoor[]\" value=\"Diabetes\" data-field-name=\"waarvoor\"  class=\"jet-form-builder__field checkboxes-field checkradio-field\"><span>Diabetes<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap checkboxes-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-checkbox\">\n\t\t\t<input type=\"checkbox\" name=\"waarvoor[]\" value=\"Hart en vaatziekten\" data-field-name=\"waarvoor\"  class=\"jet-form-builder__field checkboxes-field checkradio-field\"><span>Hart en vaatziekten<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap checkboxes-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-checkbox\">\n\t\t\t<input type=\"checkbox\" name=\"waarvoor[]\" value=\"COPD\/astma\" data-field-name=\"waarvoor\"  class=\"jet-form-builder__field checkboxes-field checkradio-field\"><span>COPD\/astma<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap checkboxes-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-checkbox\">\n\t\t\t<input type=\"checkbox\" name=\"waarvoor[]\" value=\"GGZ\" data-field-name=\"waarvoor\"  class=\"jet-form-builder__field checkboxes-field checkradio-field\"><span>GGZ<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap checkboxes-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-checkbox\">\n\t\t\t<input type=\"checkbox\" name=\"waarvoor[]\" value=\"Weet ik niet\" data-field-name=\"waarvoor\"  class=\"jet-form-builder__field checkboxes-field checkradio-field\"><span>Weet ik niet<\/span><\/label><\/div><\/div>\n<\/div>\n<\/div>\n\n\n<div class=\"wp-block-jet-engine-container jet-container jet-container--content-direction-horizontal jet-container--content-align-flex-start jet-container--content-justify-space-between wp-block-jet-engine-container\"><div class=\"jet-container__overlay   \" style=\"opacity:0.5\"><\/div><div  class=\"jet-form-builder-row field-type-submit-field\" >\n\t<div data-type=\"prev\" class=\"jet-form-builder__action-button-wrapper\">\n\t<button class=\"jet-form-builder__action-button jet-form-builder__prev-page\" type=\"button\">Vorige<\/button>\n\t<\/div>\n\t\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-submit-field\" >\n\t<div data-type=\"next\" class=\"jet-form-builder__action-button-wrapper\">\n\t<button class=\"jet-form-builder__action-button jet-form-builder__next-page\" type=\"button\" data-jfb-conditional=\"[{&quot;page_state&quot;:&quot;active&quot;}]\" data-jfb-func=\"disable\">Volgende<\/button>\n\t<\/div>\n\t\n<\/div><\/div>\n\n\n<div class=\"jet-form-builder__next-page-wrap\">\n\t\t\t<\/div>\n<\/div>\n<div class=\"jet-form-builder-page jet-form-builder-page--hidden\" data-page=\"4\" data-page-offset=\"75\">\n\n<div  class=\"jet-form-builder-row field-type-checkbox-field\" >\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">Toestemming LSP Voor informatie zie: <br>https:\/\/www.volgjezorg.nl\/toestemming <span class=\"jet-form-builder__required\">*<\/span><\/div><\/div><div class=\"jet-form-builder__fields-group checkradio-wrap\" data-jfb-sync><div class=\"jet-form-builder__field-wrap checkboxes-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-checkbox\">\n\t\t\t<input type=\"checkbox\" name=\"toestemming\" value=\"Ja\" data-field-name=\"toestemming\"  class=\"jet-form-builder__field checkboxes-field checkradio-field\" required=\"required\"><span>Ik ga akkoord met inschrijving bij deze praktijk en geef tevens toestemming om mijn dossier op te vragen bij mijn vorige zorgverlener, dit geldt ook voor informatie uitwisseling met andere zorgpartners zoals met de Spoedpost en apotheek<\/span><\/label><\/div><\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-textarea-field\" >\n<div class=\"jet-form-builder__field-wrap\">\n\t\t<textarea class=\"jet-form-builder__field textarea-field\" placeholder=\"Opmerkingen\" name=\"opmerkingen\" data-field-name=\"opmerkingen\" id=\"opmerkingen\" data-jfb-sync=\"null\"><\/textarea>\n\t<\/div>\n<\/div>\n\n\n<div class=\"wp-block-jet-engine-container jet-container jet-container--content-direction-horizontal jet-container--content-align-flex-start jet-container--content-justify-space-between wp-block-jet-engine-container\"><div class=\"jet-container__overlay   \" style=\"opacity:0.5\"><\/div><div  class=\"jet-form-builder-row field-type-submit-field\" >\n\t<div data-type=\"prev\" class=\"jet-form-builder__action-button-wrapper\">\n\t<button class=\"jet-form-builder__action-button jet-form-builder__prev-page\" type=\"button\">Vorige<\/button>\n\t<\/div>\n\t\n<\/div>\n\n<input type=\"hidden\" class=\"captcha-token\" name=\"_captcha_token\" value=\"\"\/><div  class=\"jet-form-builder-row field-type-submit-field\" >\n\t<div data-type=\"submit\" class=\"jet-form-builder__action-button-wrapper jet-form-builder__submit-wrap\">\n\t<button class=\"jet-form-builder__action-button jet-form-builder__submit submit-type-ajax\" type=\"submit\">Verzenden<\/button>\n\t<\/div>\n\t\n<\/div><\/div>\n<\/div>\t<div class=\"jet-form-builder-messages-wrap\" 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