{"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":"2026-08-29T08:16:24","modified_gmt":"2026-08-29T06:16:24","slug":"register","status":"publish","type":"praktijkinformatie","link":"https:\/\/huisartsomdehoek.nl\/en\/praktijkinformatie\/inschrijven\/","title":{"rendered":"Subscribe"},"content":{"rendered":"<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\">Subscribe<\/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-56d32c0 jedv-enabled--yes e-flex e-con-boxed e-con e-parent\" data-id=\"56d32c0\" 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<div class=\"elementor-element elementor-element-1538d66 e-con-full e-flex e-con e-child\" data-id=\"1538d66\" 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<div class=\"elementor-element elementor-element-bb9ce25 e-con-full e-flex e-con e-child\" data-id=\"bb9ce25\" 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-ed3bc26 elementor-widget elementor-widget-image\" data-id=\"ed3bc26\" 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=\"1448\" height=\"1086\" src=\"https:\/\/huisartsomdehoek.nl\/wp-content\/uploads\/2026\/08\/Inschrijven.webp\" class=\"attachment-full size-full wp-image-4468\" alt=\"\" srcset=\"https:\/\/huisartsomdehoek.nl\/wp-content\/uploads\/2026\/08\/Inschrijven.webp 1448w, https:\/\/huisartsomdehoek.nl\/wp-content\/uploads\/2026\/08\/Inschrijven-300x225.webp 300w, https:\/\/huisartsomdehoek.nl\/wp-content\/uploads\/2026\/08\/Inschrijven-1024x768.webp 1024w, https:\/\/huisartsomdehoek.nl\/wp-content\/uploads\/2026\/08\/Inschrijven-768x576.webp 768w, https:\/\/huisartsomdehoek.nl\/wp-content\/uploads\/2026\/08\/Inschrijven-16x12.webp 16w\" sizes=\"(max-width: 1448px) 100vw, 1448px\" \/>\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-dfbc744 e-con-full e-flex e-con e-child\" data-id=\"dfbc744\" 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-c2bc64d fluentform-widget-submit-button-right fluent-form-widget-step-header-yes fluent-form-widget-step-progressbar-yes fluentform-widget-submit-button-custom elementor-widget elementor-widget-fluent-form-widget\" data-id=\"c2bc64d\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"fluent-form-widget.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\n            <div class=\"fluentform-widget-wrapper fluentform-widget-align-default\">\n\n            \n            <div class='fluentform ff-inherit-theme-style fluentform_wrapper_3'><form data-form_id=\"3\" id=\"fluentform_3\" class=\"frm-fluent-form fluent_form_3 ff-el-form-top ff_form_instance_3_1 ff-form-loading ff-form-has-steps ffs_inherit_theme\" data-form_instance=\"ff_form_instance_3_1\" method=\"POST\" action=\"\" ><fieldset  style=\"border: none!important;margin: 0!important;padding: 0!important;background-color: transparent!important;box-shadow: none!important;outline: none!important; min-inline-size: 100%;\">\n                    <legend class=\"ff_screen_reader_title\" style=\"display: block; margin: 0!important;padding: 0!important;height: 0!important;text-indent: -999999px;width: 0!important;overflow:hidden;\">Subscribe<\/legend>        <div\n                style=\"display: none!important; position: absolute!important; transform: translateX(1000%)!important;\"\n                class=\"ff-el-group ff-hpsf-container\"\n        >\n            <div class=\"ff-el-input--label asterisk-right\">\n                <label for=\"ff_3_item_sf\" aria-label=\"Contact\">\n                    Contact                <\/label>\n            <\/div>\n            <div class=\"ff-el-input--content\">\n                <input type=\"text\"\n                       name=\"item_3__fluent_sf\"\n                       class=\"ff-el-form-control\"\n                       id=\"ff_3_item_sf\"\n                \/>\n            <\/div>\n        <\/div>\n                <input type=\"hidden\" id=\"__fluent_protection_token_3\" class=\"fluent-form-token-field\" name=\"__fluent_protection_token_3\">\n        <input type='hidden' name='__fluent_form_embded_post_id' value='2651' \/><input type=\"hidden\" id=\"_fluentform_3_fluentformnonce\" name=\"_fluentform_3_fluentformnonce\" value=\"78a82a9fdd\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/en\/wp-json\/wp\/v2\/praktijkinformatie\/2651\" \/><div class='ff-step-container' data-name=\"step_start-3_7\" data-disable_auto_focus=\"no\" data-enable_auto_slider=\"no\" data-enable_step_data_persistency=\"no\" data-enable_step_page_resume=\"no\" data-animation_type=\"slide\" data-progress_layout=\"top\" ><span class='ff_step_start'><\/span><div class='ff-step-body'><div class=\"fluentform-step active\" data-name=\"step_start-3_7\" data-disable_auto_focus=\"no\" data-enable_auto_slider=\"no\" data-enable_step_data_persistency=\"no\" data-enable_step_page_resume=\"no\" data-animation_type=\"slide\" data-progress_layout=\"top\" ><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-3_1\" ><h2>Subscribe<\/h2>\n<p>We are open to new registrations at a residential address with postcode 2585 AND if you do not yet have a GP in The Hague. Please fill in the form completely.\u00a0<\/p>\n<p>Do you have any further questions? Then you can make a call-back appointment by phone.\u00a0<\/p>\n<p>Please contact our doctor's assistant for this.<\/p><\/div><div data-name=\"ff_cn_id_1\"  class='ff-t-container ff-column-container ff_columns_total_3'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 31.99%;'><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_voornaam_praktijk' id='label_ff_3_input_voornaam_praktijk'>First name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_voornaam_praktijk\" class=\"ff-el-form-control\" data-name=\"input_voornaam_praktijk\" id=\"ff_3_input_voornaam_praktijk\"  aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 22.24%;'><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_input_voorletters_praktijk' id='label_ff_3_input_voorletters_praktijk'>Initial(s)<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_voorletters_praktijk\" class=\"ff-el-form-control\" data-name=\"input_voorletters_praktijk\" id=\"ff_3_input_voorletters_praktijk\"  aria-invalid=\"false\" aria-required=\"false\"><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 45.77%;'><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_achternaam_praktijk' id='label_ff_3_input_achternaam_praktijk'>Surname<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_achternaam_praktijk\" class=\"ff-el-form-control\" data-name=\"input_achternaam_praktijk\" id=\"ff_3_input_achternaam_praktijk\"  aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_2\"  class='ff-t-container ff-column-container ff_columns_total_3'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 23.32%;'><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_geboortedatum_praktijk' id='label_ff_3_input_geboortedatum_praktijk'>Date of birth<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_geboortedatum_praktijk\" class=\"ff-el-form-control\" data-name=\"input_geboortedatum_praktijk\" id=\"ff_3_input_geboortedatum_praktijk\"  aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 43.35%;'><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_geboorteplaats_praktijk' id='label_ff_3_input_geboorteplaats_praktijk'>Place of birth<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_geboorteplaats_praktijk\" class=\"ff-el-form-control\" data-name=\"input_geboorteplaats_praktijk\" id=\"ff_3_input_geboorteplaats_praktijk\"  aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_dropdown_geslacht' id='label_ff_3_dropdown_geslacht'>Gender<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown_geslacht\" id=\"ff_3_dropdown_geslacht\" class=\"ff-el-form-control\" data-name=\"dropdown_geslacht\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=\"true\" aria-labelledby=\"label_ff_3_dropdown_geslacht\"><option value=\"\">What is your gender?<\/option><option value=\"Man\"  >Man<\/option><option value=\"Vrouw\"  >Woman<\/option><option value=\"X\"  >X<\/option><\/select><\/div><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_input_meisjesnaam_praktijk' id='label_ff_3_input_meisjesnaam_praktijk'>Maiden name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_meisjesnaam_praktijk\" class=\"ff-el-form-control\" data-name=\"input_meisjesnaam_praktijk\" id=\"ff_3_input_meisjesnaam_praktijk\"  aria-invalid=\"false\" aria-required=\"false\"><\/div><\/div><div class='step-nav ff_step_nav_last'><button style='float: left;'  type='button' data-action='prev' class='ff-btn ff-btn-prev ff-btn-secondary' aria-label='Previous'>Previous<\/button><button style='float: right;'  type='button' data-action='next' class='ff-float-right ff-btn ff-btn-next ff-btn-secondary' aria-label='Next'>Next<\/button><\/div><\/div><div style='display: none;' class=\"fluentform-step\" data-name=\"form_step-3_2\" ><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-3_3\" ><h2>Address and contact details<\/h2>\n<p>Please enter your address, telephone number and email address. Please also enter the name and telephone number of the person we can contact in an emergency. Then click \"Next\".<\/p><\/div><div data-name=\"ff_cn_id_3\"  class='ff-t-container ff-column-container ff_columns_total_3'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 57.85%;'><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_text' id='label_ff_3_input_text'>Street<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text\" class=\"ff-el-form-control\" data-name=\"input_text\" id=\"ff_3_input_text\"  aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 21.53%;'><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_numeric_field' id='label_ff_3_numeric_field'>House number<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"numeric_field\" id=\"ff_3_numeric_field\" class=\"ff-el-form-control\" data-name=\"numeric_field\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 20.62%;'><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_input_text_1' id='label_ff_3_input_text_1'>Addition<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_1\" class=\"ff-el-form-control\" data-name=\"input_text_1\" id=\"ff_3_input_text_1\"  aria-invalid=\"false\" aria-required=\"false\"><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_4\"  class='ff-t-container ff-column-container ff_columns_total_3'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 22%;'><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_text_13' id='label_ff_3_input_text_13'>Postcode (numbers)<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_13\" class=\"ff-el-form-control\" data-name=\"input_text_13\" id=\"ff_3_input_text_13\"  aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 22%;'><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_text_11' id='label_ff_3_input_text_11'>Postcode (letters)<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_11\" class=\"ff-el-form-control\" placeholder=\"e.g. AB\" data-name=\"input_text_11\" id=\"ff_3_input_text_11\"  aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 56%;'><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_text_12' id='label_ff_3_input_text_12'>Location<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_12\" class=\"ff-el-form-control\" data-name=\"input_text_12\" id=\"ff_3_input_text_12\"  aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_5\"  class='ff-t-container ff-column-container ff_columns_total_2'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_phone' id='label_ff_3_phone'>Phone number<\/label><\/div><div class='ff-el-input--content'><input name=\"phone\" class=\"ff-el-form-control ff-el-phone\" type=\"tel\" data-name=\"phone\" id=\"ff_3_phone\" inputmode=\"tel\"  aria-invalid='false' aria-required=\"true\"><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50.2%;'><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_email' id='label_ff_3_email'>Email address<\/label><\/div><div class='ff-el-input--content'><input type=\"email\" name=\"email\" id=\"ff_3_email\" class=\"ff-el-form-control\" data-name=\"email\"  aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_6\"  class='ff-t-container ff-column-container ff_columns_total_2'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_input_text_4' id='label_ff_3_input_text_4'>Emergency contact name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_4\" class=\"ff-el-form-control\" data-name=\"input_text_4\" id=\"ff_3_input_text_4\"  aria-invalid=\"false\" aria-required=\"false\"><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_input_text_5' id='label_ff_3_input_text_5'>Emergency contact telephone number<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_5\" class=\"ff-el-form-control\" data-name=\"input_text_5\" id=\"ff_3_input_text_5\"  aria-invalid=\"false\" aria-required=\"false\"><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_7\"  class='ff-t-container ff-column-container ff_columns_total_2'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_dropdown_geslacht_1' id='label_ff_3_dropdown_geslacht_1'>Identification<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown_geslacht_1\" id=\"ff_3_dropdown_geslacht_1\" class=\"ff-el-form-control\" data-name=\"dropdown_geslacht_1\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=\"true\" aria-labelledby=\"label_ff_3_dropdown_geslacht_1\"><option value=\"\">Which document?<\/option><option value=\"Paspoort\"  >Passport<\/option><option value=\"Rijbewijs\"  >Driving licence<\/option><option value=\"ID-kaart\"  >ID card<\/option><\/select><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_text_15' id='label_ff_3_input_text_15'>Document number<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_15\" class=\"ff-el-form-control\" data-name=\"input_text_15\" id=\"ff_3_input_text_15\"  aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><\/div><\/div><div class='step-nav ff_step_nav_last'><button style='float: left;'  type='button' data-action='prev' class='ff-btn ff-btn-prev ff-btn-secondary' aria-label='Previous'>Previous<\/button><button style='float: right;'  type='button' data-action='next' class='ff-float-right ff-btn ff-btn-next ff-btn-secondary' aria-label='Next'>Next<\/button><\/div><\/div><div style='display: none;' class=\"fluentform-step\" data-name=\"form_step-3_4\" ><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-3_5\" ><h2>Additional information<\/h2>\n<p>To complete your registration, we need some additional information. Please fill in these details and then click \"Submit\".<\/p><\/div><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_numeric_field_1' id='label_ff_3_numeric_field_1'>BSN number<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"numeric_field_1\" id=\"ff_3_numeric_field_1\" class=\"ff-el-form-control\" data-name=\"numeric_field_1\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><div data-name=\"ff_cn_id_8\"  class='ff-t-container ff-column-container ff_columns_total_2'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_text_7' id='label_ff_3_input_text_7'>Health insurer<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_7\" class=\"ff-el-form-control\" data-name=\"input_text_7\" id=\"ff_3_input_text_7\"  aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_text_6' id='label_ff_3_input_text_6'>Policy number<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_6\" class=\"ff-el-form-control\" data-name=\"input_text_6\" id=\"ff_3_input_text_6\"  aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_text_8' id='label_ff_3_input_text_8'>Pharmacy (new)<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_8\" class=\"ff-el-form-control\" data-name=\"input_text_8\" id=\"ff_3_input_text_8\"  aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><div data-name=\"ff_cn_id_9\"  class='ff-t-container ff-column-container ff_columns_total_2'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_text_10' id='label_ff_3_input_text_10'>Name of previous GP<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_10\" class=\"ff-el-form-control\" data-name=\"input_text_10\" id=\"ff_3_input_text_10\"  aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_input_text_9' id='label_ff_3_input_text_9'>Previous GP\u2019s practice<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_9\" class=\"ff-el-form-control\" data-name=\"input_text_9\" id=\"ff_3_input_text_9\"  aria-invalid=\"false\" aria-required=\"false\"><\/div><\/div><\/div><\/div><div class='step-nav ff_step_nav_last'><button style='float: left;'  type='button' data-action='prev' class='ff-btn ff-btn-prev ff-btn-secondary' aria-label='Previous'>Previous<\/button><button style='float: right;'  type='button' data-action='next' class='ff-float-right ff-btn ff-btn-next ff-btn-secondary' aria-label='Next'>Next<\/button><\/div><\/div><div style='display: none;' class=\"fluentform-step\" data-name=\"form_step-3_6\" ><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_datetime_2' id='label_ff_3_datetime_2'>Do you have any comments?<\/label><\/div><div class='ff-el-input--content'><input  aria-label='Do you have any comments? Use the arrow keys to navigate through the dates. Press Enter to select a date.'  aria-haspopup='dialog' data-type-datepicker data-format='d\/m\/Y' type=\"text\" name=\"datetime_2\" id=\"ff_3_datetime_2\" class=\"ff-el-form-control ff-el-datepicker\" data-name=\"datetime_2\"  aria-invalid='false' aria-required=\"true\"><\/div><\/div><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  >I agree to register with this practice<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_1_362e74c445f0adafae6f875209aa234a'><input  type=\"radio\" name=\"input_radio_1\" data-name=\"input_radio_1\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Ja\"  id='input_radio_1_362e74c445f0adafae6f875209aa234a' aria-label='Yes' aria-invalid='false' aria-required=\"true\"> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_1_5d39971659cf8c160d93e161019ee5d3'><input  type=\"radio\" name=\"input_radio_1\" data-name=\"input_radio_1\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Nee\"  id='input_radio_1_5d39971659cf8c160d93e161019ee5d3' aria-label='No' aria-invalid='false' aria-required=\"true\"> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  >I give my consent for my medical records to be requested from my previous GP \/ healthcare provider<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_2_5622c215046c9b136ec0bee966f2a0ca'><input  type=\"radio\" name=\"input_radio_2\" data-name=\"input_radio_2\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Ja\"  id='input_radio_2_5622c215046c9b136ec0bee966f2a0ca' aria-label='Yes' aria-invalid='false' aria-required=\"true\"> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_2_eca32330f38bd96b1b0cee025d8e94b3'><input  type=\"radio\" name=\"input_radio_2\" data-name=\"input_radio_2\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Nee\"  id='input_radio_2_eca32330f38bd96b1b0cee025d8e94b3' aria-label='No' aria-invalid='false' aria-required=\"true\"> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  >I give my consent for my medical details to be shared with healthcare partners such as the A&amp;E department, the hospital and the chemist\u2019s<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_3_0d7b960316de804cedc8c5c5450b4c39'><input  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