{"id":2207,"date":"2021-06-07T14:31:02","date_gmt":"2021-06-07T13:31:02","guid":{"rendered":"https:\/\/www.oxycure.be\/?page_id=2207"},"modified":"2022-01-19T14:33:23","modified_gmt":"2022-01-19T13:33:23","slug":"interventie-aanvraag","status":"publish","type":"page","link":"https:\/\/www.oxycure.be\/nl\/interventie-aanvraag\/","title":{"rendered":"Interventie aanvraag"},"content":{"rendered":"<h2>Interventie aanvraag<\/h2>\n<p>* <span lang=\"NL-BE\"> Verplicht in te vullen velden<\/span><\/p>\n\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f2348-o1\" lang=\"fr-FR\" dir=\"ltr\" data-wpcf7-id=\"2348\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/nl\/wp-json\/wp\/v2\/pages\/2207#wpcf7-f2348-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Formulaire de contact\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"2348\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.5\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"fr_FR\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f2348-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;:2348,&quot;conditions&quot;:[{&quot;then_field&quot;:&quot;pharmacie-selected&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;support-type&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Apotheek&quot;}]},{&quot;then_field&quot;:&quot;pmrs-pharmacie-selected&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;pmrs-pharmacie&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;ja&quot;}]},{&quot;then_field&quot;:&quot;medecin-selected&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;support-type&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Huisarts&quot;}]},{&quot;then_field&quot;:&quot;mrs-selected&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;support-type&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;WZC&quot;}]},{&quot;then_field&quot;:&quot;hopital-mrs-selected&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;checkmrshopital&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;ja&quot;}]},{&quot;then_field&quot;:&quot;hopital-selected&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;support-type&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Ziekenhuis&quot;}]},{&quot;then_field&quot;:&quot;hypoxemie-selected&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;therapie-type&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Acute hypoxemie&quot;}]},{&quot;then_field&quot;:&quot;palliatif-selected&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;therapie-type&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Palliatief&quot;}]},{&quot;then_field&quot;:&quot;oxycure-selected&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;therapie-type&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Oxycure Prepaid 3&quot;}]},{&quot;then_field&quot;:&quot;cluster-selected&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;therapie-type&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Cluster Headache&quot;}]},{&quot;then_field&quot;:&quot;longterme-selected&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;therapie-type&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Lange termijn&quot;},{&quot;if_field&quot;:&quot;support-type&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Ziekenhuis&quot;}]},{&quot;then_field&quot;:&quot;autre-selected&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;therapie-type&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Andere&quot;}]},{&quot;then_field&quot;:&quot;pmrs-pharmacie-nonselected&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;pmrs-pharmacie&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;nee&quot;}]},{&quot;then_field&quot;:&quot;pmrs-medecin-selected&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;pmrs-medecin&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;ja&quot;}]},{&quot;then_field&quot;:&quot;pmrs-medecin-nonselected&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;pmrs-medecin&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;nee&quot;}]},{&quot;then_field&quot;:&quot;pmrs-hopital-selected&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;pmrs-hopital&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;ja&quot;}]},{&quot;then_field&quot;:&quot;pmrs-hopital-nonselected&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;pmrs-hopital&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;nee&quot;}]},{&quot;then_field&quot;:&quot;concent-reserve-selected&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;concent-reserve&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;ja&quot;}]}],&quot;settings&quot;:{&quot;animation&quot;:&quot;no&quot;,&quot;animation_intime&quot;:&quot;200&quot;,&quot;animation_outtime&quot;:&quot;200&quot;,&quot;conditions_ui&quot;:&quot;normal&quot;,&quot;notice_dismissed&quot;:&quot;&quot;,&quot;notice_dismissed_rollback-cf7-5.5.2&quot;:true,&quot;notice_dismissed_rollback-cf7-5.5.5&quot;:true,&quot;notice_dismissed_rollback-cf7-5.5.6.1&quot;:true,&quot;notice_dismissed_rollback-cf7-5.8.2&quot;:true,&quot;notice_dismissed_rollback-cf7-6.1.1&quot;:true,&quot;notice_dismissed_rollback-cf7-6.1.4&quot;:true}}\" \/><input type=\"hidden\" name=\"_wpcf7_recaptcha_response\" value=\"\" \/>\n<\/fieldset>\n<h3>GEGEVENS\n<\/h3>\n<h4>Ik ben\u2026\n<\/h4>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"support-type\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"support-type\"><option value=\"\">-- Maak een keuze --<\/option><option value=\"Apotheek\">Apotheek<\/option><option value=\"Huisarts\">Huisarts<\/option><option value=\"WZC\">WZC<\/option><option value=\"Ziekenhuis\">Ziekenhuis<\/option><\/select><\/span>\n<\/p>\n<div data-id=\"pharmacie-selected\" data-orig_data_id=\"pharmacie-selected\"  class=\"\" data-class=\"wpcf7cf_group\">\n\t<p><b>Apotheek<\/b><br \/>\nNaam van de apotheek*:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"ppharma\"><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=\"ppharma\" \/><\/span><br \/>\nAdres:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"ppharma-adresse\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"ppharma-adresse\" \/><\/span><br \/>\nPostcode:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"ppharma-cp\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"ppharma-cp\" \/><\/span><br \/>\nPlaats:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"ppharma-ville\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"ppharma-ville\" \/><\/span><br \/>\nContactpersoon*:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"ppharma-contact\"><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=\"ppharma-contact\" \/><\/span><br \/>\nTelefoon*:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"ppharma-tel\"><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=\"ppharma-tel\" \/><\/span><br \/>\nE-mail*:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"ppharma-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=\"ppharma-email\" \/><\/span>\n\t<\/p>\n\t<p><b>Pati\u00ebnt<\/b><br \/>\nNaam*:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"ppatient\"><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=\"ppatient\" \/><\/span><br \/>\nVoornaam*:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"pprenom\"><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=\"pprenom\" \/><\/span><br \/>\nGeboortedatum*:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"ppatnaissance\"><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=\"ppatnaissance\" \/><\/span><br \/>\nWZC*:<span class=\"wpcf7-form-control-wrap\" data-name=\"pmrs-pharmacie\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"pmrs-pharmacie\" value=\"ja\" \/><span class=\"wpcf7-list-item-label\">ja<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"pmrs-pharmacie\" value=\"nee\" \/><span class=\"wpcf7-list-item-label\">nee<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n\t<div data-id=\"pmrs-pharmacie-selected\" data-orig_data_id=\"pmrs-pharmacie-selected\"  class=\"\" data-class=\"wpcf7cf_group\">\n\t\t<p><b>WZC<\/b><br \/>\nNaam* WZC:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"pmrsnom\"><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=\"pmrsnom\" \/><\/span><br \/>\nTelefoon*:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"pmrstel\"><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=\"pmrstel\" \/><\/span><br \/>\nAdres WZC:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"ppatadresse\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"ppatadresse\" \/><\/span><br \/>\nPostcode:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"ppatcp\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"ppatcp\" \/><\/span><br \/>\nPlaats:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"ppatville\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"ppatville\" \/><\/span><br \/>\nVerdiep\/afdeling:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"pmrsetage\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"pmrsetage\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div data-id=\"pmrs-pharmacie-nonselected\" data-orig_data_id=\"pmrs-pharmacie-nonselected\"  class=\"\" data-class=\"wpcf7cf_group\">\n\t\t<p>Adres pati\u00ebnt:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"ppatadresse\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"ppatadresse\" \/><\/span><br \/>\nPostcode:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"ppatcp\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"ppatcp\" \/><\/span><br \/>\nPlaats:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"ppatville\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"ppatville\" \/><\/span><br \/>\nTelefoon\/GSM*:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"ppattel\"><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=\"ppattel\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<p><b>Voorschrijvende arts<\/b><br \/>\nNaam:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"pmed-presc-nom\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"pmed-presc-nom\" \/><\/span><br \/>\nVoornaam:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"pmed-presc-prenom\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"pmed-presc-prenom\" \/><\/span><br \/>\nAdres:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"pmed-presc-adresse\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"pmed-presc-adresse\" \/><\/span><br \/>\nPostcode:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"pmed-presc-cp\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"pmed-presc-cp\" \/><\/span><br \/>\nPlaats:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"pmed-presc-ville\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"pmed-presc-ville\" \/><\/span><br \/>\nTelefoon:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"pmed-presc-tel\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"pmed-presc-tel\" \/><\/span>\n\t<\/p>\n\t<p><b>Huisarts <\/b><br \/>\nNaam:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"pmed-gen-nom\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"pmed-gen-nom\" \/><\/span><br \/>\nVoornaam:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"pmed-gen-prenom\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"pmed-gen-prenom\" \/><\/span><br \/>\nAdres:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"pmed-gen-adresse\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"pmed-gen-adresse\" \/><\/span><br \/>\nPoscode:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"pmed-gen-cp\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"pmed-gen-cp\" \/><\/span><br \/>\nPlaats:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"pmed-gen-ville\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"pmed-gen-ville\" \/><\/span><br \/>\nTelefoon:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"pmed-presc-tel\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"pmed-presc-tel\" \/><\/span>\n\t<\/p>\n<\/div>\n<div data-id=\"medecin-selected\" data-orig_data_id=\"medecin-selected\"  class=\"\" data-class=\"wpcf7cf_group\">\n\t<p><b>Voorschrijvende arts<\/b><br \/>\nNaam*:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"mmed-gen-nom\"><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=\"mmed-gen-nom\" \/><\/span><br \/>\nVoornaam:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"mmed-gen-prenom\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mmed-gen-prenom\" \/><\/span><br \/>\nAdres:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"mmed-gen-adresse\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mmed-gen-adresse\" \/><\/span><br \/>\nPostcode:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"mmed-gen-cp\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mmed-gen-cp\" \/><\/span><br \/>\nPlaats:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"mmed-gen-ville\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mmed-gen-ville\" \/><\/span><br \/>\nContactpersoon*:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"mmed-gen-contact\"><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=\"mmed-gen-contact\" \/><\/span><br \/>\nTelefoon*:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"mmed-gen-tel\"><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=\"mmed-gen-tel\" \/><\/span><br \/>\nE-mail*:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"mmed-gen-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=\"mmed-gen-email\" \/><\/span>\n\t<\/p>\n\t<p><b>Pati\u00ebnt<\/b><br \/>\nNaam*:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"mpatient\"><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=\"mpatient\" \/><\/span><br \/>\nVoornaam*:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"mprenom\"><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=\"mprenom\" \/><\/span><br \/>\nGeboortedatum *:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"mpatnaissance\"><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=\"mpatnaissance\" \/><\/span><br \/>\nWZC*:<span class=\"wpcf7-form-control-wrap\" data-name=\"pmrs-medecin\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"pmrs-medecin\" value=\"ja\" \/><span class=\"wpcf7-list-item-label\">ja<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"pmrs-medecin\" value=\"nee\" \/><span class=\"wpcf7-list-item-label\">nee<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n\t<div data-id=\"pmrs-medecin-selected\" data-orig_data_id=\"pmrs-medecin-selected\"  class=\"\" data-class=\"wpcf7cf_group\">\n\t\t<p><b>WZC<\/b><br \/>\nNaam* WZC:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"mmrsnom\"><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=\"mmrsnom\" \/><\/span><br \/>\nTelefoon*:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"mmrstel\"><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=\"mmrstel\" \/><\/span><br \/>\nAdres WZC:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"mmrsadresse\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mmrsadresse\" \/><\/span><br \/>\nPoscode:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"mmrscp\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mmrscp\" \/><\/span><br \/>\nPlaats:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"mmrsville\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mmrsville\" \/><\/span><br \/>\nVerdiep\/afdeling:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"mmrsetage\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mmrsetage\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div data-id=\"pmrs-medecin-nonselected\" data-orig_data_id=\"pmrs-medecin-nonselected\"  class=\"\" data-class=\"wpcf7cf_group\">\n\t\t<p>Adres pati\u00ebnt:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"mpatadresse\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mpatadresse\" \/><\/span><br \/>\nPostcode:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"mpatcp\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mpatcp\" \/><\/span><br \/>\nPlaats:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"mpatville\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mpatville\" \/><\/span><br \/>\nTelefoon\/GSM*:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"mpattel\"><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=\"mpattel\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<p><b>Apotheek <\/b><br \/>\nNaam van de apotheek*:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"mpharmacie\"><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=\"mpharmacie\" \/><\/span><br \/>\nAdres:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"mpharmacie-adresse\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mpharmacie-adresse\" \/><\/span><br \/>\nPoscode:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"mpharmacie-cp\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mpharmacie-cp\" \/><\/span><br \/>\nPlaats:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"mpharmacie-ville\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mpharmacie-ville\" \/><\/span><br \/>\nTelefoon*:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"mpharmacie-tel\"><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=\"mpharmacie-tel\" \/><\/span>\n\t<\/p>\n<\/div>\n<div data-id=\"mrs-selected\" data-orig_data_id=\"mrs-selected\"  class=\"\" data-class=\"wpcf7cf_group\">\n\t<p><b>WZC<\/b><br \/>\nNaam*:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"mrs-nom\"><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=\"mrs-nom\" \/><\/span><br \/>\nAdres:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"mrs-adresse\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mrs-adresse\" \/><\/span><br \/>\nPoscode:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"mrs-cp\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mrs-cp\" \/><\/span><br \/>\nPlaats:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"mrs-ville\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mrs-ville\" \/><\/span><br \/>\nContactpersoon*:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"mrs-contact\"><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=\"mrs-contact\" \/><\/span><br \/>\nTelefoon*:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"mrs-tel\"><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=\"mrs-tel\" \/><\/span><br \/>\nE-mail*:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"mrs-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=\"mrs-email\" \/><\/span>\n\t<\/p>\n\t<p>Reserveconcentrator:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"concent-reserve\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"concent-reserve\" value=\"ja\" \/><span class=\"wpcf7-list-item-label\">ja<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"concent-reserve\" value=\"nee\" \/><span class=\"wpcf7-list-item-label\">nee<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n\t<div data-id=\"concent-reserve-selected\" data-orig_data_id=\"concent-reserve-selected\"  class=\"\" data-class=\"wpcf7cf_group\">\n\t\t<p>Aantal overblijvende uren*:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"mrs-heures\"><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=\"mrs-heures\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div data-id=\"concent-reserve-nonselected\" data-orig_data_id=\"concent-reserve-nonselected\"  class=\"\" data-class=\"wpcf7cf_group\">\n\t<\/div>\n\t<p><b>Pati\u00ebnt<\/b><br \/>\nNaam*:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"mrspatient\"><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=\"mrspatient\" \/><\/span><br \/>\nVoornaam*:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"mrsprenom\"><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=\"mrsprenom\" \/><\/span><br \/>\nGeboortedatum *:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"mrsnaissance\"><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=\"mrsnaissance\" \/><\/span><br \/>\nVerdiep\/afdeling:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"mrsetage\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mrsetage\" \/><\/span>\n\t<\/p>\n\t<p><b>Apotheek <\/b><br \/>\nNaam van de apotheek *:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"mrspharmacie\"><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=\"mrspharmacie\" \/><\/span><br \/>\nAdres:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"mrspharmacie-adresse\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mrspharmacie-adresse\" \/><\/span><br \/>\nPoscode:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"mrspharmacie-cp\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mrspharmacie-cp\" \/><\/span><br \/>\nPlaats:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"mrspharmacie-ville\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mrspharmacie-ville\" \/><\/span><br \/>\nTelefoon*:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"mrspharmacie-tel\"><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=\"mrspharmacie-tel\" \/><\/span>\n\t<\/p>\n\t<p><b>Voorschrijvende arts<\/b><br \/>\nNaam:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"mrsmed-presc-nom\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mrsmed-presc-nom\" \/><\/span><br \/>\nVoornaam:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"mrsmed-presc-prenom\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mrsmed-presc-prenom\" \/><\/span><br \/>\nAdres:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"mrsmed-presc-adresse\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mrsmed-presc-adresse\" \/><\/span><br \/>\nPoscode:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"mrsmed-presc-cp\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mrsmed-presc-cp\" \/><\/span><br \/>\nPlaats:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"mrsmed-presc-ville\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mrsmed-presc-ville\" \/><\/span><br \/>\nTelefoon:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"mrsmed-presc-tel\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mrsmed-presc-tel\" \/><\/span>\n\t<\/p>\n\t<p>Functie:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"fonction\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"fonction\"><option value=\"\">&#8212;Veuillez choisir une option&#8212;<\/option><option value=\"huisarts\">huisarts<\/option><option value=\"Pneumoloog\">Pneumoloog<\/option><option value=\"Oncoloog\">Oncoloog<\/option><option value=\"Geriater\">Geriater<\/option><option value=\"Neuroloog\">Neuroloog<\/option><option value=\"Andere\">Andere<\/option><\/select><\/span><br \/>\nZiekenhuis:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"checkmrshopital\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"checkmrshopital\" value=\"ja\" \/><span class=\"wpcf7-list-item-label\">ja<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"checkmrshopital\" value=\"nee\" \/><span class=\"wpcf7-list-item-label\">nee<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n\t<div data-id=\"hopital-mrs-selected\" data-orig_data_id=\"hopital-mrs-selected\"  class=\"\" data-class=\"wpcf7cf_group\">\n\t\t<p><b>Ziekenhuis<\/b><br \/>\nNaam:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"mrshopital-nom\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mrshopital-nom\" \/><\/span><br \/>\nPlaats:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"mrshopital-ville\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mrshopital-ville\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div data-id=\"hopital-selected\" data-orig_data_id=\"hopital-selected\"  class=\"\" data-class=\"wpcf7cf_group\">\n\t<p><b>Ziekenhuis<\/b><br \/>\nNaam van het ziekenhuis*:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"hhopital-nom\"><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=\"hhopital-nom\" \/><\/span><br \/>\nVoorschrijvende arts*:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"hhopitaldemandeur\"><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=\"hhopitaldemandeur\" \/><\/span><br \/>\nFunctie:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"fonction\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"fonction\"><option value=\"\">&#8212;Veuillez choisir une option&#8212;<\/option><option value=\"huisarts\">huisarts<\/option><option value=\"Pneumoloog\">Pneumoloog<\/option><option value=\"Oncoloog\">Oncoloog<\/option><option value=\"Geriater\">Geriater<\/option><option value=\"Neuroloog\">Neuroloog<\/option><option value=\"Andere\">Andere<\/option><\/select><\/span><br \/>\nAdres:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"hhopital-adresse\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"hhopital-adresse\" \/><\/span><br \/>\nPosctode:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"hhopital-cp\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"hhopital-cp\" \/><\/span><br \/>\nPlaats:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"hhopital-ville\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"hhopital-ville\" \/><\/span><br \/>\nContactpersoon*:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"hhopital-contact\"><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=\"hhopital-contact\" \/><\/span><br \/>\nTelefoon*:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"hhopital-tel\"><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=\"hhopital-tel\" \/><\/span><br \/>\nE-mail*:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"hhopital-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=\"hhopital-email\" \/><\/span>\n\t<\/p>\n\t<p><b>Pati\u00ebnt<\/b><br \/>\nNaam*:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"hpatient\"><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=\"hpatient\" \/><\/span><br \/>\nVoornaam*:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"hprenom\"><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=\"hprenom\" \/><\/span><br \/>\nGeboortedatum*:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"hnaissance\"><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=\"hnaissance\" \/><\/span><br \/>\nWZC*:<span class=\"wpcf7-form-control-wrap\" data-name=\"pmrs-hopital\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"pmrs-hopital\" value=\"ja\" \/><span class=\"wpcf7-list-item-label\">ja<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"pmrs-hopital\" value=\"nee\" \/><span class=\"wpcf7-list-item-label\">nee<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n\t<div data-id=\"pmrs-hopital-selected\" data-orig_data_id=\"pmrs-hopital-selected\"  class=\"\" data-class=\"wpcf7cf_group\">\n\t\t<p><b>WZC<\/b><br \/>\nNaam* WZC:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"hmrsnom\"><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=\"hmrsnom\" \/><\/span><br \/>\nTelefoon*:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"hmrs-tel\"><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=\"hmrs-tel\" \/><\/span><br \/>\nAdres WZC:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"hmrs-adresse\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"hmrs-adresse\" \/><\/span><br \/>\nPostcode:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"hmrs-cp\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"hmrs-cp\" \/><\/span><br \/>\nPlaats:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"hmrs-ville\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"hmrs-ville\" \/><\/span><br \/>\nVerdiep\/afdeling:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"hmrsetage\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"hmrsetage\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div data-id=\"pmrs-hopital-nonselected\" data-orig_data_id=\"pmrs-hopital-nonselected\"  class=\"\" data-class=\"wpcf7cf_group\">\n\t\t<p>Adres pati\u00ebnt:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"hpatient-adresse\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"hpatient-adresse\" \/><\/span><br \/>\nPostcode:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"hpatient-cp\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"hpatient-cp\" \/><\/span><br \/>\nPlaats:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"hpatient-ville\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"hpatient-ville\" \/><\/span><br \/>\nTelefoon\/GSM*:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"hpatient-tel\"><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=\"hpatient-tel\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<p><b>Apotheek<\/b><br \/>\nNaam van de apotheek *:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"hpharmacie\"><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=\"hpharmacie\" \/><\/span><br \/>\nAdres:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"hpharmacie-adresse\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"hpharmacie-adresse\" \/><\/span><br \/>\nPostcode:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"hpharmacie-cp\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"hpharmacie-cp\" \/><\/span><br \/>\nPlaats:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"hpharmacie-ville\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"hpharmacie-ville\" \/><\/span><br \/>\nTelefoon*:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"hpharmacie-tel\"><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=\"hpharmacie-tel\" \/><\/span>\n\t<\/p>\n\t<p><b>Huisarts<\/b><br \/>\nNaam:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"hmed-presc-nom\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"hmed-presc-nom\" \/><\/span><br \/>\nVoornaam:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"hmed-presc-prenom\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"hmed-presc-prenom\" \/><\/span><br \/>\nAdres:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"hmed-presc-adresse\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"hmed-presc-adresse\" \/><\/span><br \/>\nPostcode:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"hmed-presc-cp\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"hmed-presc-cp\" \/><\/span><br \/>\nPlaats:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"hmed-presc-ville\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"hmed-presc-ville\" \/><\/span><br \/>\nTelefoon:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"hmed-presc-tel\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"hmed-presc-tel\" \/><\/span>\n\t<\/p>\n<\/div>\n<h3>THERAPIE\n<\/h3>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"therapie-type\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"therapie-type\"><option value=\"\">-- Maak een keuze --<\/option><option value=\"Acute hypoxemie\">Acute hypoxemie<\/option><option value=\"Palliatief\">Palliatief<\/option><option value=\"Oxycure Prepaid 3\">Oxycure Prepaid 3<\/option><option value=\"Cluster Headache\">Cluster Headache<\/option><option value=\"Lange termijn\">Lange termijn<\/option><option value=\"Andere\">Andere<\/option><\/select><\/span>\n<\/p>\n<p>Slechts 1 keuze mogelijk.<br \/>\nlange termijn (enkel voor ziekenhuizen)\n<\/p>\n<div data-id=\"hypoxemie-selected\" data-orig_data_id=\"hypoxemie-selected\"  class=\"\" data-class=\"wpcf7cf_group\">\n\t<p><b>Acute Hypoxemie<\/b><br \/>\nTherapie:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"hatherapie-lpm\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"hatherapie-lpm\"><option value=\"\">&#8212;Veuillez choisir une option&#8212;<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"andere\">andere<\/option><\/select><\/span> LPM<br \/>\nIndien andere:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"haautrelpm\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"haautrelpm\" \/><\/span> LPM<br \/>\nAantal uren\/dag:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"haheuresjour\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"haheuresjour\" \/><\/span><br \/>\nBevochtiger*:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"hahumidificateur\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"hahumidificateur\" value=\"ja\" \/><span class=\"wpcf7-list-item-label\">ja<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"hahumidificateur\" value=\"nee\" \/><span class=\"wpcf7-list-item-label\">nee<\/span><\/label><\/span><\/span><\/span><br \/>\nReservezuurstoffles:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"habouteilleres\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"habouteilleres\" value=\"ja\" \/><span class=\"wpcf7-list-item-label\">ja<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"habouteilleres\" value=\"nee\" \/><span class=\"wpcf7-list-item-label\">nee<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div data-id=\"palliatif-selected\" data-orig_data_id=\"palliatif-selected\"  class=\"\" data-class=\"wpcf7cf_group\">\n\t<p><b>Palliatief<\/b><br \/>\nTherapie:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"ptherapie-lpm\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"ptherapie-lpm\"><option value=\"\">&#8212;Veuillez choisir une option&#8212;<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"andere\">andere<\/option><\/select><\/span> LPM<br \/>\nIndien andere:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"pautrelpm\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"pautrelpm\" \/><\/span> LPM<br \/>\nAantal uren\/dag:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"pheuresjour\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"pheuresjour\" \/><\/span><br \/>\nBevochtiger*:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"phumidificateur\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"phumidificateur\" value=\"ja\" \/><span class=\"wpcf7-list-item-label\">ja<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"phumidificateur\" value=\"nee\" \/><span class=\"wpcf7-list-item-label\">nee<\/span><\/label><\/span><\/span><\/span><br \/>\nReservezuurstoffles:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"pbouteilleres\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"pbouteilleres\" value=\"ja\" \/><span class=\"wpcf7-list-item-label\">ja<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"pbouteilleres\" value=\"nee\" \/><span class=\"wpcf7-list-item-label\">nee<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div data-id=\"oxycure-selected\" data-orig_data_id=\"oxycure-selected\"  class=\"\" data-class=\"wpcf7cf_group\">\n\t<p><b>Oxycure Prepaid 3<\/b><br \/>\nTherapie:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"o3therapie-lpm\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"o3therapie-lpm\"><option value=\"\">&#8212;Veuillez choisir une option&#8212;<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"andere\">andere<\/option><\/select><\/span> LPM<br \/>\nIndien andere:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"o3autrelpm\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"o3autrelpm\" \/><\/span> LPM<br \/>\nAantal uren\/dag:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"o3heuresjour\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"o3heuresjour\" \/><\/span><br \/>\nBevochtiger*:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"o3humidificateur\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"o3humidificateur\" value=\"ja\" \/><span class=\"wpcf7-list-item-label\">ja<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"o3humidificateur\" value=\"nee\" \/><span class=\"wpcf7-list-item-label\">nee<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div data-id=\"cluster-selected\" data-orig_data_id=\"cluster-selected\"  class=\"\" data-class=\"wpcf7cf_group\">\n\t<p><b>Cluster Headache<\/b><br \/>\nTherapie:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"chtherapie-lpm\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"chtherapie-lpm\"><option value=\"\">&#8212;Veuillez choisir une option&#8212;<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"andere\">andere<\/option><\/select><\/span> LPM<br \/>\nIndien andere:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"chautrelpm\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"chautrelpm\" \/><\/span> LPM<br \/>\nAantal uren\/dag:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"chheuresjour\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"chheuresjour\" \/><\/span>\n\t<\/p>\n<\/div>\n<div data-id=\"longterme-selected\" data-orig_data_id=\"longterme-selected\"  class=\"\" data-class=\"wpcf7cf_group\">\n\t<p><b>Langetermijn <\/b><br \/>\nStartdatum overeenkomst:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"ltdebut\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"ltdebut\" \/><\/span><br \/>\nDuur: <span class=\"wpcf7-form-control-wrap\" data-name=\"ltheuresjour\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"ltheuresjour\" value=\"4 maanden\" \/><span class=\"wpcf7-list-item-label\">4 maanden<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"ltheuresjour\" value=\"1 jaar\" \/><span class=\"wpcf7-list-item-label\">1 jaar<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"therapieconvention\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"therapieconvention\"><option value=\"\">-- Maak een keuze --<\/option><option value=\"Pseudocode 797 252: concentrator\">Pseudocode 797 252: concentrator<\/option><option value=\"Pseudocode 797 274: concentrator + compressor -&gt; we plaatsen: concentrator + draagbare concentrator\">Pseudocode 797 274: concentrator + compressor -&gt; we plaatsen: concentrator + draagbare concentrator<\/option><option value=\"Pseudocode 797 296: concentrator + draagbare concentrator\">Pseudocode 797 296: concentrator + draagbare concentrator<\/option><option value=\"Pseudocode 797 370: draagbare concentrator\">Pseudocode 797 370: draagbare concentrator<\/option><option value=\"Pseudocode 797 311: vloeibare zuurstof\">Pseudocode 797 311: vloeibare zuurstof<\/option><\/select><\/span><br \/>\nTherapie:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"lttherapie-lpm\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"lttherapie-lpm\"><option value=\"\">&#8212;Veuillez choisir une option&#8212;<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"autre\">autre<\/option><\/select><\/span> LPM<br \/>\nBevochtiger*:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"lthumidificateur\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"lthumidificateur\" value=\"ja\" \/><span class=\"wpcf7-list-item-label\">ja<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"lthumidificateur\" value=\"nee\" \/><span class=\"wpcf7-list-item-label\">nee<\/span><\/label><\/span><\/span><\/span><br \/>\nReservezuurstoffles:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"ltbouteilleres\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"ltbouteilleres\" value=\"ja\" \/><span class=\"wpcf7-list-item-label\">ja<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"ltbouteilleres\" value=\"nee\" \/><span class=\"wpcf7-list-item-label\">nee<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div data-id=\"autre-selected\" data-orig_data_id=\"autre-selected\"  class=\"\" data-class=\"wpcf7cf_group\">\n\t<p><b>Andere<\/b><br \/>\nVrije text:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"textelibre\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"textelibre\"><\/textarea><\/span>\n\t<\/p>\n<\/div>\n<h3>OPMERKINGEN\n<\/h3>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"commentaires\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"commentaires\"><\/textarea><\/span>\n<\/p>\n<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Verzenden\" \/>\n<\/p><p style=\"display: none !important;\" class=\"akismet-fields-container\" data-prefix=\"_wpcf7_ak_\"><label>&#916;<textarea name=\"_wpcf7_ak_hp_textarea\" cols=\"45\" rows=\"8\" maxlength=\"100\"><\/textarea><\/label><input type=\"hidden\" id=\"ak_js_1\" name=\"_wpcf7_ak_js\" value=\"13\"\/><script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\ndocument.getElementById( \"ak_js_1\" ).setAttribute( \"value\", ( new Date() ).getTime() );\n\/* ]]> *\/\n<\/script>\n<\/p><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n\n<p>&nbsp;<\/p>\n<h3><span lang=\"NL-BE\">Voor dringende aanvragen, gelieve ons te contacteren via het telefoonnummer 081\/221590<\/span><\/h3>\n<div id=\"ConnectiveDocSignExtentionInstalled\" data-extension-version=\"1.0.4\"><\/div>\n","protected":false},"excerpt":{"rendered":"<p>Interventie aanvraag * Verplicht in te vullen velden &nbsp; Voor dringende aanvragen, gelieve ons te contacteren via het telefoonnummer 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