{"id":1141,"date":"2023-01-26T22:07:57","date_gmt":"2023-01-26T21:07:57","guid":{"rendered":"https:\/\/hapleiden.nl\/?page_id=1141"},"modified":"2025-04-22T10:33:30","modified_gmt":"2025-04-22T08:33:30","slug":"inschrijfformulier","status":"publish","type":"page","link":"https:\/\/praktijkvrijheidslaan.nl\/en\/inschrijfformulier\/","title":{"rendered":"Register"},"content":{"rendered":"<div data-elementor-type=\"wp-page\" data-elementor-id=\"1141\" class=\"elementor elementor-1141\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-6bda23d elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"6bda23d\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-71a5644\" data-id=\"71a5644\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-e99e99a elementor-widget elementor-widget-text-editor\" data-id=\"e99e99a\" data-element_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>At the moment, the practice is only open to family members of our patients and people who have come to live in Leiden (see postcodes) <span style=\"text-decoration: underline;\">and do not yet have a GP in Leiden<\/span>.<br \/><strong>2311, 2312, 2313, 2321, 2322, 2323, 2324<\/strong><\/p><p>We always make an appointment for an introductory conversation when you register as a new patient in our practice. <a href=\"https:\/\/www.thuisarts.nl\/kennismakingsgesprek-met-huisarts\" target=\"_blank\" rel=\"noopener\">You can prepare for this conversation with this handy checklist from Thuisarts.nl<\/a>.<\/p><p>Completed data will be deleted once processed. We store your data in our secure medical environment.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-8a9b151 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"8a9b151\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-4320f06\" data-id=\"4320f06\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-370a056 elementor-widget elementor-widget-shortcode\" data-id=\"370a056\" data-element_type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\"><div class=\"forminator-ui forminator-custom-form forminator-custom-form-1144 forminator-design--default  forminator_ajax\" data-forminator-render=\"0\" data-form=\"forminator-module-1144\" data-uid=\"69f3856a4484d\"><br\/><\/div><form\n\t\t\t\tid=\"forminator-module-1144\"\n\t\t\t\tclass=\"forminator-ui forminator-custom-form forminator-custom-form-1144 forminator-design--default  forminator_ajax\"\n\t\t\t\tmethod=\"post\"\n\t\t\t\tdata-forminator-render=\"0\"\n\t\t\t\tdata-form-id=\"1144\"\n\t\t\t\t data-color-option=\"default\" data-design=\"default\" data-grid=\"open\" style=\"display: none;\"\n\t\t\t\tdata-uid=\"69f3856a4484d\" action=\"\"\n\t\t\t><div role=\"alert\" aria-live=\"polite\" class=\"forminator-response-message forminator-error\" aria-hidden=\"true\"><\/div><div class=\"forminator-pagination-progress\" aria-hidden=\"true\"><\/div><div tabindex=\"-1\" role=\"tabpanel\" id=\"forminator-custom-form-1144--page-0\" class=\"forminator-pagination forminator-pagination-start\" aria-labelledby=\"forminator-custom-form-1144--page-0-label\" data-step=\"0\" data-label=\"Verstuur\" data-name=\"page-break-1\"><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"group-1\" class=\"forminator-field-group forminator-col forminator-col-12\"><label class=\"forminator-label forminator-repeater-label\">Person<\/label><span class=\"forminator-description forminator-repeater-description\">You can register children under the age of 16 together with yourself if they reside at the same address. Inhabitants over 16 years old must fill out the form separately.<\/span><div class=\"forminator-all-group-copies forminator-repeater-field\"><div class=\"forminator-grouped-fields\" data-options=\"{&quot;is_repeater&quot;:true,&quot;min_type&quot;:&quot;custom&quot;,&quot;max_type&quot;:&quot;custom&quot;,&quot;min&quot;:1,&quot;max&quot;:10,&quot;add_text&quot;:&quot;Voeg nog een persoon toe&quot;,&quot;remove_text&quot;:&quot;Verwijder&quot;,&quot;action_element_type&quot;:&quot;button&quot;}\"><div class=\"forminator-row\"><div id=\"name-3\" class=\"forminator-field-name forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-name-3_69f3856a4484d\" id=\"forminator-field-name-3_69f3856a4484d-label\" class=\"forminator-label\">First Name <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-3\" value=\"\" placeholder=\"\" id=\"forminator-field-name-3_69f3856a4484d\" class=\"forminator-input forminator-name--field\" aria-required=\"true\" autocomplete=\"name\" \/><\/div><\/div><div id=\"name-4\" class=\"forminator-field-name forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-name-4_69f3856a4484d\" id=\"forminator-field-name-4_69f3856a4484d-label\" class=\"forminator-label\">Last Name <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-4\" value=\"\" placeholder=\"\" id=\"forminator-field-name-4_69f3856a4484d\" class=\"forminator-input forminator-name--field\" aria-required=\"true\" autocomplete=\"name\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-2\" class=\"forminator-field-name forminator-col forminator-col-4\"><div class=\"forminator-field\"><label for=\"forminator-field-name-2_69f3856a4484d\" id=\"forminator-field-name-2_69f3856a4484d-label\" class=\"forminator-label\">Initials<\/label><input type=\"text\" name=\"name-2\" value=\"\" placeholder=\"\" id=\"forminator-field-name-2_69f3856a4484d\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" autocomplete=\"name\" \/><\/div><\/div><div id=\"name-5\" class=\"forminator-field-name forminator-col forminator-col-4\"><div class=\"forminator-field\"><label for=\"forminator-field-name-5_69f3856a4484d\" id=\"forminator-field-name-5_69f3856a4484d-label\" class=\"forminator-label\">Maiden Name<\/label><input type=\"text\" name=\"name-5\" value=\"\" placeholder=\"\" id=\"forminator-field-name-5_69f3856a4484d\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" autocomplete=\"name\" aria-describedby=\"forminator-field-name-5_69f3856a4484d-description\" \/><span id=\"forminator-field-name-5_69f3856a4484d-description\" class=\"forminator-description\">Surname at birth (if changed during marriage)<\/span><\/div><\/div><div id=\"select-2\" class=\"forminator-field-select forminator-col forminator-col-4\"><div class=\"forminator-field\"><label for=\"forminator-form-1144__field--select-2_69f3856a4484d\" id=\"forminator-form-1144__field--select-2_69f3856a4484d-label\" class=\"forminator-label\">Gender<\/label><select  id=\"forminator-form-1144__field--select-2_69f3856a4484d\" class=\"forminator-select--field forminator-select2 forminator-select2-multiple\" data-required=\"\" name=\"select-2\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\" data-search-placeholder=\"\" data-checkbox=\"false\" data-allow-clear=\"false\" aria-labelledby=\"forminator-form-1144__field--select-2_69f3856a4484d-label\"><option value=\"one\"  data-calculation=\"0\">Male<\/option><option value=\"two\"  data-calculation=\"0\">Female<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-1\" class=\"forminator-field-date forminator-col forminator-col-12\"><label for=\"forminator-field-date-1\" id=\"forminator-field-date-1-label\" class=\"forminator-label\">Date of Birth <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-date-input\"><div class=\"forminator-row\" data-multiple=\"true\"><div id=\"date-1-day\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-date-1-day_69f3856a4484d\" class=\"forminator-label\">Day <span class=\"forminator-required\">*<\/span><\/label><input type=\"number\" min=\"1\" max=\"31\" name=\"date-1-day\" value=\"\" placeholder=\"\" id=\"forminator-field-date-1-day_69f3856a4484d\" class=\"forminator-input\" data-field=\"day\" data-format=\"dd-mm-yy\" data-parent=\"date-1\" \/><\/div><\/div><div id=\"date-1-month\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-date-1-month_69f3856a4484d\" class=\"forminator-label\">Month <span class=\"forminator-required\">*<\/span><\/label><input type=\"number\" min=\"1\" max=\"12\" name=\"date-1-month\" value=\"\" placeholder=\"\" id=\"forminator-field-date-1-month_69f3856a4484d\" class=\"forminator-input\" data-field=\"month\" data-format=\"dd-mm-yy\" data-parent=\"date-1\" \/><\/div><\/div><div id=\"date-1-year\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-date-1-year_69f3856a4484d\" class=\"forminator-label\">Year <span class=\"forminator-required\">*<\/span><\/label><input type=\"number\" min=\"1\" name=\"date-1-year\" placeholder=\"\" id=\"forminator-field-date-1-year_69f3856a4484d\" class=\"forminator-input\" data-field=\"year\" value=\"\" data-format=\"dd-mm-yy\" data-parent=\"date-1\" \/><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-1\" class=\"forminator-field-text forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-text-1_69f3856a4484d\" id=\"forminator-field-text-1_69f3856a4484d-label\" class=\"forminator-label\">Place of Birth<\/label><input type=\"text\" name=\"text-1\" value=\"\" placeholder=\"\" id=\"forminator-field-text-1_69f3856a4484d\" class=\"forminator-input forminator-name--field\" data-required=\"\" aria-describedby=\"forminator-field-text-1_69f3856a4484d-description\" \/><span id=\"forminator-field-text-1_69f3856a4484d-description\" class=\"forminator-description\">If outside the Netherlands, please indicate city and country<\/span><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-1\" class=\"forminator-field-select forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-form-1144__field--select-1_69f3856a4484d\" id=\"forminator-form-1144__field--select-1_69f3856a4484d-label\" class=\"forminator-label\">Marital Status<\/label><select  id=\"forminator-form-1144__field--select-1_69f3856a4484d\" class=\"forminator-select--field forminator-select2 forminator-select2-multiple\" data-required=\"\" name=\"select-1\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\" data-search-placeholder=\"\" data-checkbox=\"false\" data-allow-clear=\"false\" aria-labelledby=\"forminator-form-1144__field--select-1_69f3856a4484d-label\"><option value=\"one\"  data-calculation=\"0\">Single<\/option><option value=\"two\"  data-calculation=\"0\">Married<\/option><option value=\"Partnerschap\"  data-calculation=\"0\">Civil Partnership<\/option><option value=\"Gescheiden-na-huwelijk\"  data-calculation=\"0\">Divorced after marriage<\/option><option value=\"Gescheiden-na-partnerschap\"  data-calculation=\"0\">Divorced after civil partnership<\/option><option value=\"Verweduwd-na-huwelijk\"  data-calculation=\"0\">Widowed after marriage<\/option><option value=\"Verweduwd-na-partnerschap\"  data-calculation=\"0\">Widowed after civil partnership<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row forminator-action-buttons\"><div class=\"forminator-col forminator-col-12\"><input type=\"button\" value=\"Add another person\" class=\"forminator-repeater-action-button forminator-repeater-add\" \/><input type=\"button\" value=\"Remove\" class=\"forminator-repeater-action-button forminator-repeater-remove\" \/><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div tabindex=\"-1\" role=\"tabpanel\" id=\"forminator-custom-form-1144--page-1\" class=\"forminator-pagination\" aria-labelledby=\"forminator-custom-form-1144--page-1-label\" aria-hidden=\"true\" data-step=\"1\" data-label=\"Basisgegevens\" data-name=\"page-break-2\" hidden><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"section-3\" class=\"forminator-field-section forminator-col forminator-col-12\"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Address information<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-3\" class=\"forminator-field-text forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-text-3_69f3856a4484d\" id=\"forminator-field-text-3_69f3856a4484d-label\" class=\"forminator-label\">Street name and number <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-3\" value=\"\" placeholder=\"E.g. Examplestreet 7\" id=\"forminator-field-text-3_69f3856a4484d\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-5\" class=\"forminator-field-text forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-text-5_69f3856a4484d\" id=\"forminator-field-text-5_69f3856a4484d-label\" class=\"forminator-label\">Postal code <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-5\" value=\"\" placeholder=\"\" id=\"forminator-field-text-5_69f3856a4484d\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><div id=\"text-4\" class=\"forminator-field-text forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-text-4_69f3856a4484d\" id=\"forminator-field-text-4_69f3856a4484d-label\" class=\"forminator-label\">City <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-4\" value=\"\" placeholder=\"\" id=\"forminator-field-text-4_69f3856a4484d\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-2\" class=\"forminator-field-section forminator-col forminator-col-12\"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Contact information<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"email-1\" class=\"forminator-field-email forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-email-1_69f3856a4484d\" id=\"forminator-field-email-1_69f3856a4484d-label\" class=\"forminator-label\">Email address <span class=\"forminator-required\">*<\/span><\/label><input type=\"email\" name=\"email-1\" value=\"\" placeholder=\"\" id=\"forminator-field-email-1_69f3856a4484d\" class=\"forminator-input forminator-email--field\" data-required=\"1\" aria-required=\"true\" autocomplete=\"email\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"phone-1\" class=\"forminator-field-phone forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-phone-1_69f3856a4484d\" id=\"forminator-field-phone-1_69f3856a4484d-label\" class=\"forminator-label\">Phone Number <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"phone-1\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-1_69f3856a4484d\" class=\"forminator-input forminator-field--phone\" data-required=\"1\" aria-required=\"true\" autocomplete=\"off\" data-national_mode=\"disabled\" data-country=\"nl\" data-validation=\"international\" \/><\/div><\/div><\/div><\/div><\/div><div tabindex=\"-1\" role=\"tabpanel\" id=\"forminator-custom-form-1144--page-2\" class=\"forminator-pagination\" aria-labelledby=\"forminator-custom-form-1144--page-2-label\" aria-hidden=\"true\" data-step=\"2\" data-label=\"Contactgegevens\" data-name=\"page-break-3\" hidden><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"text-6\" class=\"forminator-field-text forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-text-6_69f3856a4484d\" id=\"forminator-field-text-6_69f3856a4484d-label\" class=\"forminator-label\">Name of health insurance company <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-6\" value=\"\" placeholder=\"\" id=\"forminator-field-text-6_69f3856a4484d\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><div id=\"text-7\" class=\"forminator-field-text forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-text-7_69f3856a4484d\" id=\"forminator-field-text-7_69f3856a4484d-label\" class=\"forminator-label\">Insurance policy number <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-7\" value=\"\" placeholder=\"\" id=\"forminator-field-text-7_69f3856a4484d\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-2\" class=\"forminator-field-date forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-date-2-picker_69f3856a4484d\" id=\"forminator-field-date-2-picker_69f3856a4484d-label\" class=\"forminator-label\">Insurance policy start date <span class=\"forminator-required\">*<\/span><\/label><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-2\" value=\"\" placeholder=\"\" id=\"forminator-field-date-2-picker_69f3856a4484d\" class=\"forminator-input forminator-datepicker\" data-required=\"1\" data-format=\"dd-mm-yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" aria-describedby=\"forminator-field-date-2-picker_69f3856a4484d-description\" \/><span id=\"forminator-field-date-2-picker_69f3856a4484d-description\" class=\"forminator-description\">If you have recently switched to a different insurance policy, the start date is usually January 1st.<\/span><\/div><\/div><div id=\"text-8\" class=\"forminator-field-text forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-text-8_69f3856a4484d\" id=\"forminator-field-text-8_69f3856a4484d-label\" class=\"forminator-label\">BSN <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-8\" value=\"\" placeholder=\"\" id=\"forminator-field-text-8_69f3856a4484d\" class=\"forminator-input forminator-name--field\" data-required=\"1\" maxlength=\"9\" aria-describedby=\"forminator-field-text-8_69f3856a4484d-description\" \/><span id=\"forminator-field-text-8_69f3856a4484d-description\" class=\"forminator-description\">Citizen Service Number (can be found on your Dutch driver's license and ID card)<span data-limit=\"9\" data-type=\"characters\">0 \/ 9<\/span><\/span><\/div><\/div><\/div><\/div><\/div><div tabindex=\"-1\" role=\"tabpanel\" id=\"forminator-custom-form-1144--page-3\" class=\"forminator-pagination\" aria-labelledby=\"forminator-custom-form-1144--page-3-label\" aria-hidden=\"true\" data-step=\"3\" data-label=\"Page  3\" data-name=\"\" hidden><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"name-6\" class=\"forminator-field-name forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-name-6_69f3856a4484d\" id=\"forminator-field-name-6_69f3856a4484d-label\" class=\"forminator-label\">Name of current General Practitioner\/GP Practice<\/label><input type=\"text\" name=\"name-6\" value=\"\" placeholder=\"\" id=\"forminator-field-name-6_69f3856a4484d\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" autocomplete=\"name\" \/><\/div><\/div><div id=\"text-11\" class=\"forminator-field-text forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-text-11_69f3856a4484d\" id=\"forminator-field-text-11_69f3856a4484d-label\" class=\"forminator-label\">Location of GP Practice<\/label><input type=\"text\" name=\"text-11\" value=\"\" placeholder=\"\" id=\"forminator-field-text-11_69f3856a4484d\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-12\" class=\"forminator-field-text forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-text-12_69f3856a4484d\" id=\"forminator-field-text-12_69f3856a4484d-label\" class=\"forminator-label\">Which pharmacy in Leiden would you like to register at? <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-12\" value=\"\" placeholder=\"\" id=\"forminator-field-text-12_69f3856a4484d\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-1\" class=\"forminator-field-html forminator-col forminator-col-12\"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-1\"><p>U kunt <a href=\"https:\/\/www.apotheek.nl\/vind-een-apotheek?q=2321JR\" target=\"_blank\" rel=\"noopener\">op deze kaart een apotheek in de buurt vinden<\/a>.<\/p><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"consent-1\" class=\"forminator-field-consent forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-consent-1_69f3856a4484d\" id=\"forminator-field-consent-1_69f3856a4484d-label\" class=\"forminator-label\">Data transfer <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-checkbox__wrapper\"><label id=\"forminator-field-consent-1_69f3856a4484d__label\" class=\"forminator-checkbox forminator-consent\" aria-labelledby=\"forminator-field-consent-1_69f3856a4484d-label\" aria-hidden=\"true\"><input type=\"checkbox\" name=\"consent-1\" id=\"forminator-field-consent-1_69f3856a4484d\" value=\"checked\" aria-labelledby=\"forminator-field-consent-1_69f3856a4484d-label\" aria-describedby=\"forminator-field-consent-1_69f3856a4484d__description\" data-required=\"true\" aria-required=\"true\" \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><\/label><div id=\"forminator-field-consent-1_69f3856a4484d__description\" class=\"forminator-checkbox__label forminator-consent__label\"><p>I agree to the retrieval and exchange of my data with my current GP. Retrieving your medical records from your previous GP is necessary for providing medical care.<\/p><\/div><\/div><\/div><\/div><\/div><\/div><button class=\"forminator-button forminator-pagination-submit\" style=\"display: none;\" disabled>Submit Form<\/button><\/div><input type=\"hidden\" name=\"referer_url\" value=\"\" \/><input type=\"hidden\" id=\"forminator_nonce\" name=\"forminator_nonce\" value=\"b7ba65ea58\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/en\/wp-json\/wp\/v2\/pages\/1141\" \/><input type=\"hidden\" name=\"form_id\" value=\"1144\"><input type=\"hidden\" name=\"page_id\" value=\"1141\"><input type=\"hidden\" name=\"form_type\" value=\"default\"><input type=\"hidden\" name=\"current_url\" value=\"https:\/\/praktijkvrijheidslaan.nl\/en\/inschrijfformulier\/\"><input type=\"hidden\" name=\"render_id\" value=\"0\"><input type=\"hidden\" name=\"action\" value=\"forminator_submit_form_custom-forms\"><label for=\"input_23\" class=\"forminator-hidden\" aria-hidden=\"true\">Please do not fill in this field. <input id=\"input_23\" type=\"text\" name=\"input_23\" value=\"\" autocomplete=\"off\"><\/label><input type=\"hidden\" name=\"trp-form-language\" value=\"en\"\/><\/form><\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>","protected":false},"excerpt":{"rendered":"<p>Op dit moment is de praktijk alleen nog open voor gezinsleden van onze pati\u00ebnten en mensen die nieuw in Leiden\u00a0(zie postcodes)\u00a0zijn komen [&hellip;]<\/p>","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-1141","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v26.4 - 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