{"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":"2026-09-17T18:10:01","modified_gmt":"2026-09-17T16:10:01","slug":"kayit","status":"publish","type":"praktijkinformatie","link":"https:\/\/huisartsen.gcschalkwijk.nl\/tr\/praktijkinformatie\/inschrijven\/","title":{"rendered":"Abone Olun"},"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-aca32b1 e-flex e-con-boxed e-con e-parent\" data-id=\"aca32b1\" 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-98e57f9 e-con-full e-flex e-con e-child\" data-id=\"98e57f9\" 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-eed762e e-con-full e-flex e-con e-child\" data-id=\"eed762e\" 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-cb7e508 elementor-widget elementor-widget-text-editor\" data-id=\"cb7e508\" 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 style=\"font-weight: 400;\">Bewoners die net in Haarlem zijn komen wonen en vallen onder\u00a0postcodegebied 2034 t\/m 2037\u00a0kunnen ingeschreven worden d.m.v. de volgende link <strong><a href=\"https:\/\/huisartsen-gezondheidscentrum-schalkwijk.mijnpraktijk.nl\/\" target=\"_blank\" rel=\"noopener\" data-outlook-id=\"c2183ebf-d914-4248-8902-a681ad898a1f\">Inschrijven<\/a><\/strong><\/p><p style=\"font-weight: 400;\">Inschrijven mag ook via het volgende <strong><a href=\"https:\/\/huisartsen.gcschalkwijk.nl\/wp-content\/uploads\/2026\/01\/20241007-Inschrijfformulier-patient.pdf\" target=\"_blank\" rel=\"noopener\" data-outlook-id=\"0d902c9e-a98d-4165-8990-fcd5d0dc03bd\">formulier<\/a>\u00a0<\/strong><\/p><p style=\"font-weight: 400;\">Het inschrijfformulier kunt u printen en inleveren bij de assistenten op de 2e of 3e etage, hierna zal de assistente u verder uitleg geven.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\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-aeb4dfa jedv-enabled--yes elementor-hidden-desktop elementor-hidden-tablet elementor-hidden-mobile e-flex e-con-boxed e-con e-parent\" data-id=\"aeb4dfa\" 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-7706703 e-con-full e-flex e-con e-child\" data-id=\"7706703\" 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-99ecd4a e-con-full e-flex e-con e-child\" data-id=\"99ecd4a\" 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-510a433 elementor-widget elementor-widget-image\" data-id=\"510a433\" 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:\/\/huisartsen.gcschalkwijk.nl\/wp-content\/uploads\/2026\/08\/Inschrijven.webp\" class=\"attachment-full size-full wp-image-4564\" alt=\"\" srcset=\"https:\/\/huisartsen.gcschalkwijk.nl\/wp-content\/uploads\/2026\/08\/Inschrijven.webp 1448w, https:\/\/huisartsen.gcschalkwijk.nl\/wp-content\/uploads\/2026\/08\/Inschrijven-300x225.webp 300w, https:\/\/huisartsen.gcschalkwijk.nl\/wp-content\/uploads\/2026\/08\/Inschrijven-1024x768.webp 1024w, https:\/\/huisartsen.gcschalkwijk.nl\/wp-content\/uploads\/2026\/08\/Inschrijven-768x576.webp 768w, https:\/\/huisartsen.gcschalkwijk.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-84e896d e-con-full e-flex e-con e-child\" data-id=\"84e896d\" 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-9cd9e8f 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=\"9cd9e8f\" 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\" ><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;\">Inschrijven<\/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=\"Subscribe\">\n                    Subscribe                <\/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=\"ba373e15f7\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/tr\/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>Inschrijven<\/h2>\n<p>Wij zijn open voor nieuwe inschrijvingen. Vul uw gegevens in en klik op \"Volgende\"<\/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'>Voornaam<\/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'>Voorletter(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'>Achternaam<\/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'>Geboortedatum<\/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'>Geboorteplaats<\/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'>Geslacht<\/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=\"\">Wat is uw geslacht?<\/option><option value=\"Man\"  >Man<\/option><option value=\"Vrouw\"  >Vrouw<\/option><option value=\"X\"  >X<\/option><\/select><\/div><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_input_meisjesnaam_praktijk' id='label_ff_3_input_meisjesnaam_praktijk'>Meisjesnaam<\/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='Vorige'>Vorige<\/button><button style='float: right;'  type='button' data-action='next' class='ff-float-right ff-btn ff-btn-next ff-btn-secondary' aria-label='Volgende'>Volgende<\/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>Adres - en contactgegevens<\/h2>\n<p>Vul uw adres, telefoonnummer en e-mailadres in. Vul daarnaast ook de naam en telefoonnummer in van de persoon die wij kunnen bellen in geval van nood. Klik daarna op \"Volgende\".<\/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'>Straat<\/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'>Huisnummer<\/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'>Toevoeging<\/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 (cijfers)<\/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=\"bijv. 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'>Plaats<\/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'>Telefoonnummer<\/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'>E-mailadres<\/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'>Noodcontact naam<\/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'>Noodcontact telefoonnummer<\/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 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='Vorige'>Vorige<\/button><button style='float: right;'  type='button' data-action='next' class='ff-float-right ff-btn ff-btn-next ff-btn-secondary' aria-label='Volgende'>Volgende<\/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>Aanvullende gegevens<\/h2>\n<p>Om uw inschrijving compleet te maken, hebben wij nog aanvullende gegevens nodig. Vul deze gegevens in klik vervolgens op \"Verzenden\".<\/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 nummer<\/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_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 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'>Zorgverzekeraar<\/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'>Polisnummer<\/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'>Apotheek (nieuwe)<\/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_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_10' id='label_ff_3_input_text_10'>Naam vorige huisarts<\/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'>Plaats vorige huisarts<\/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='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_datetime' id='label_ff_3_datetime'>Gewenste inschrijfdatum<\/label><\/div><div class='ff-el-input--content'><input  aria-label='Gewenste inschrijfdatum Use arrow keys to navigate dates. Press enter to select a date.'  aria-haspopup='dialog' data-type-datepicker data-format='d\/m\/Y' type=\"text\" name=\"datetime\" id=\"ff_3_datetime\" class=\"ff-el-form-control ff-el-datepicker\" data-name=\"datetime\"  aria-invalid='false' aria-required=true><\/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='Vorige'>Vorige<\/button><button style='float: right;'  type='button' data-action='next' class='ff-float-right ff-btn ff-btn-next ff-btn-secondary' aria-label='Volgende'>Volgende<\/button><\/div><\/div><div style='display: none;' class=\" fluentform-step\" data-name=\"form_step-3_6\" ><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  >Ik ga akkoord met inschrijving bij deze praktijk<\/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_32a01eee1f93f7e570ac53ffe6500093'><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_32a01eee1f93f7e570ac53ffe6500093' aria-label='Ja' aria-invalid='false' aria-required=true> <span>Ja<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_1_36948e186e136c6f5a4604e5f42f31ca'><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_36948e186e136c6f5a4604e5f42f31ca' aria-label='Nee' aria-invalid='false' aria-required=true> <span>Nee<\/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  >Ik geef toestemming om mijn dossier op te vragen bij mijn vorige huisarts \/ zorgverlener<\/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_5dc71d2d2adec8e0b1a74e139c8c012d'><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_5dc71d2d2adec8e0b1a74e139c8c012d' aria-label='Ja' aria-invalid='false' aria-required=true> <span>Ja<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_2_6b25ed6803cfdec8955527c82851fa15'><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_6b25ed6803cfdec8955527c82851fa15' aria-label='Nee' aria-invalid='false' aria-required=true> <span>Nee<\/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  >Ik geef toestemming om mijn medische gegevens uit te wisselen met zorgpartners zoals de spoedpost, ziekenhuis en apotheek<\/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_1ba92a0b33c07e5f93b24546b0f42ac3'><input  type=\"radio\" name=\"input_radio_3\" data-name=\"input_radio_3\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Ja\"  id='input_radio_3_1ba92a0b33c07e5f93b24546b0f42ac3' aria-label='Ja' aria-invalid='false' aria-required=true> <span>Ja<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_3_7180a3279d45e8b037c020825565c502'><input  type=\"radio\" name=\"input_radio_3\" data-name=\"input_radio_3\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Nee\"  id='input_radio_3_7180a3279d45e8b037c020825565c502' aria-label='Nee' aria-invalid='false' aria-required=true> <span>Nee<\/span><\/label><\/div><\/div><\/div>        <div class=\"ff-step-t-container ff-inner_submit_container ff-column-container ff_columns_total_2\">\n            <div class=\"ff-t-cell ff-t-column-1\"><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='Vorige'>Vorige<\/button><\/div><\/div>\n            <div class=\"ff-t-cell ff-t-column-2\">\n                <div class='ff-form-inline-style' hidden><style>form.fluent_form_3 .wpf_has_custom_css.ff-btn-submit { background-color:rgba(63, 153, 205, 1);border-color:rgba(63, 153, 205, 1);color:#ffffff; }form.fluent_form_3 .wpf_has_custom_css.ff-btn-submit:hover { background-color:#ffffff;border-color:rgba(63, 153, 205, 1);color:rgba(63, 153, 205, 1); } <\/style><\/div><div class='ff-el-group ff-text-left 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