{"id":530,"date":"2023-08-29T08:29:10","date_gmt":"2023-08-29T08:29:10","guid":{"rendered":"https:\/\/praktijkdebuitenruimte.nl\/?page_id=530"},"modified":"2023-08-29T08:35:12","modified_gmt":"2023-08-29T08:35:12","slug":"aanmelden","status":"publish","type":"page","link":"https:\/\/praktijkdebuitenruimte.nl\/index.php\/aanmelden\/","title":{"rendered":"Aanmeldformulier"},"content":{"rendered":"<style id=\"wpforms-css-vars-root\">\n\t\t\t\t:root {\n\t\t\t\t\t--wpforms-field-border-radius: 3px;\n--wpforms-field-border-style: solid;\n--wpforms-field-border-size: 1px;\n--wpforms-field-background-color: #ffffff;\n--wpforms-field-border-color: rgba( 0, 0, 0, 0.25 );\n--wpforms-field-border-color-spare: rgba( 0, 0, 0, 0.25 );\n--wpforms-field-text-color: rgba( 0, 0, 0, 0.7 );\n--wpforms-field-menu-color: #ffffff;\n--wpforms-label-color: rgba( 0, 0, 0, 0.85 );\n--wpforms-label-sublabel-color: rgba( 0, 0, 0, 0.55 );\n--wpforms-label-error-color: #d63637;\n--wpforms-button-border-radius: 3px;\n--wpforms-button-border-style: none;\n--wpforms-button-border-size: 1px;\n--wpforms-button-background-color: #066aab;\n--wpforms-button-border-color: #066aab;\n--wpforms-button-text-color: #ffffff;\n--wpforms-page-break-color: #066aab;\n--wpforms-background-image: none;\n--wpforms-background-position: center center;\n--wpforms-background-repeat: no-repeat;\n--wpforms-background-size: cover;\n--wpforms-background-width: 100px;\n--wpforms-background-height: 100px;\n--wpforms-background-color: rgba( 0, 0, 0, 0 );\n--wpforms-background-url: none;\n--wpforms-container-padding: 0px;\n--wpforms-container-border-style: none;\n--wpforms-container-border-width: 1px;\n--wpforms-container-border-color: #000000;\n--wpforms-container-border-radius: 3px;\n--wpforms-field-size-input-height: 43px;\n--wpforms-field-size-input-spacing: 15px;\n--wpforms-field-size-font-size: 16px;\n--wpforms-field-size-line-height: 19px;\n--wpforms-field-size-padding-h: 14px;\n--wpforms-field-size-checkbox-size: 16px;\n--wpforms-field-size-sublabel-spacing: 5px;\n--wpforms-field-size-icon-size: 1;\n--wpforms-label-size-font-size: 16px;\n--wpforms-label-size-line-height: 19px;\n--wpforms-label-size-sublabel-font-size: 14px;\n--wpforms-label-size-sublabel-line-height: 17px;\n--wpforms-button-size-font-size: 17px;\n--wpforms-button-size-height: 41px;\n--wpforms-button-size-padding-h: 15px;\n--wpforms-button-size-margin-top: 10px;\n--wpforms-container-shadow-size-box-shadow: none;\n\n\t\t\t\t}\n\t\t\t<\/style><div class=\"wpforms-container wpforms-container-full wpforms-block wpforms-block-4a0c3b0b-f21e-4cbb-b13d-d4f93b0ba4ef wpforms-render-modern\" id=\"wpforms-519\"><form id=\"wpforms-form-519\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"519\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/index.php\/wp-json\/wp\/v2\/pages\/530\" data-token=\"8e0dc57239f2fb238559c7671c870a35\" data-token-time=\"1787144752\"><noscript class=\"wpforms-error-noscript\">Schakel JavaScript in je browser in om dit formulier in te vullen.<\/noscript><div class=\"wpforms-hidden\" id=\"wpforms-error-noscript\">Schakel JavaScript in je browser in om dit formulier in te vullen.<\/div><div class=\"wpforms-field-container\"><div id=\"wpforms-519-field_1-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"1\"><label class=\"wpforms-field-label\" for=\"wpforms-519-field_1\">Voornaam <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-519-field_1\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][1]\" aria-errormessage=\"wpforms-519-field_1-error\" required><\/div><div id=\"wpforms-519-field_2-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"2\"><label class=\"wpforms-field-label\" for=\"wpforms-519-field_2\">Voorletters <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-519-field_2\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][2]\" aria-errormessage=\"wpforms-519-field_2-error\" required><\/div><div id=\"wpforms-519-field_3-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"3\"><label class=\"wpforms-field-label\" for=\"wpforms-519-field_3\">Tussenvoegsels<\/label><input type=\"text\" id=\"wpforms-519-field_3\" class=\"wpforms-field-medium\" name=\"wpforms[fields][3]\" aria-errormessage=\"wpforms-519-field_3-error\" ><\/div><div id=\"wpforms-519-field_4-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"4\"><label class=\"wpforms-field-label\" for=\"wpforms-519-field_4\">Achternaam <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-519-field_4\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][4]\" aria-errormessage=\"wpforms-519-field_4-error\" required><\/div><div id=\"wpforms-519-field_5-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"5\"><label class=\"wpforms-field-label\" for=\"wpforms-519-field_5\">Geboortenaam\/meisjesnaam<\/label><input type=\"text\" id=\"wpforms-519-field_5\" class=\"wpforms-field-medium\" name=\"wpforms[fields][5]\" aria-errormessage=\"wpforms-519-field_5-error\" ><\/div><div id=\"wpforms-519-field_6-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"6\"><label class=\"wpforms-field-label\" for=\"wpforms-519-field_6\">Geslacht <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-519-field_6\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][6]\" aria-errormessage=\"wpforms-519-field_6-error\" required><\/div><div id=\"wpforms-519-field_26-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"26\"><label class=\"wpforms-field-label\" for=\"wpforms-519-field_26\">Geboortedatum <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-519-field_26\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][26]\" aria-errormessage=\"wpforms-519-field_26-error\" required><\/div><div id=\"wpforms-519-field_9-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"9\"><label class=\"wpforms-field-label\" for=\"wpforms-519-field_9\">BSN nummer <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-519-field_9\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][9]\" aria-errormessage=\"wpforms-519-field_9-error\" required><\/div><div id=\"wpforms-519-field_10-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"10\"><label class=\"wpforms-field-label\" for=\"wpforms-519-field_10\">Burgerlijke staat <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-519-field_10\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][10]\" aria-errormessage=\"wpforms-519-field_10-error\" required><\/div><div id=\"wpforms-519-field_11-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"11\"><label class=\"wpforms-field-label\" for=\"wpforms-519-field_11\">Straatnaam <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-519-field_11\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][11]\" aria-errormessage=\"wpforms-519-field_11-error\" required><\/div><div id=\"wpforms-519-field_12-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"12\"><label class=\"wpforms-field-label\" for=\"wpforms-519-field_12\">Huisnummer <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-519-field_12\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][12]\" aria-errormessage=\"wpforms-519-field_12-error\" required><\/div><div id=\"wpforms-519-field_13-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"13\"><label class=\"wpforms-field-label\" for=\"wpforms-519-field_13\">Huisnummer toevoeging<\/label><input type=\"text\" id=\"wpforms-519-field_13\" class=\"wpforms-field-medium\" name=\"wpforms[fields][13]\" aria-errormessage=\"wpforms-519-field_13-error\" ><\/div><div id=\"wpforms-519-field_14-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-519-field_14\">Postcode <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-519-field_14\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][14]\" aria-errormessage=\"wpforms-519-field_14-error\" required><\/div><div id=\"wpforms-519-field_15-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"15\"><label class=\"wpforms-field-label\" for=\"wpforms-519-field_15\">Woonplaats <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-519-field_15\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][15]\" aria-errormessage=\"wpforms-519-field_15-error\" required><\/div><div id=\"wpforms-519-field_16-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"16\"><label class=\"wpforms-field-label\" for=\"wpforms-519-field_16\">Telefoonnummer <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-519-field_16\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][16]\" aria-errormessage=\"wpforms-519-field_16-error\" required><\/div><div id=\"wpforms-519-field_17-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"17\"><label class=\"wpforms-field-label\" for=\"wpforms-519-field_17\">E-mailadres <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-519-field_17\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][17]\" aria-errormessage=\"wpforms-519-field_17-error\" required><\/div><div id=\"wpforms-519-field_21-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"21\"><label class=\"wpforms-field-label\" for=\"wpforms-519-field_21\">Zorgverzekeraar <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-519-field_21\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][21]\" aria-errormessage=\"wpforms-519-field_21-error\" aria-describedby=\"wpforms-519-field_21-description\" required><div id=\"wpforms-519-field_21-description\" class=\"wpforms-field-description\">Deze gegevens nodig voor de factuur, ook al heb ik geen contracten met zorgverzekeraars<\/div><\/div><div id=\"wpforms-519-field_22-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"22\"><label class=\"wpforms-field-label\" for=\"wpforms-519-field_22\">Huisarts  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-519-field_22\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][22]\" aria-errormessage=\"wpforms-519-field_22-error\" aria-describedby=\"wpforms-519-field_22-description\" required><div id=\"wpforms-519-field_22-description\" class=\"wpforms-field-description\">Naam\/praktijk en plaats<\/div><\/div><div id=\"wpforms-519-field_23-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"23\"><fieldset><legend class=\"wpforms-field-label\">Verwijsbrief <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-519-field_23\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-519-field_23_1\" name=\"wpforms[fields][23][]\" value=\"De huisarts verwijst digitaal via Zorgdomein\" aria-errormessage=\"wpforms-519-field_23_1-error\" aria-describedby=\"wpforms-519-field_23-description\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-519-field_23_1\">De huisarts verwijst digitaal via Zorgdomein<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-519-field_23_2\" name=\"wpforms[fields][23][]\" value=\"Ik neem mijn verwijsbrief mee naar de eerste afspraak\" aria-errormessage=\"wpforms-519-field_23_2-error\" aria-describedby=\"wpforms-519-field_23-description\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-519-field_23_2\">Ik neem mijn verwijsbrief mee naar de eerste afspraak<\/label><\/li><\/ul><div id=\"wpforms-519-field_23-description\" class=\"wpforms-field-description\">Let op: als u de verwijsbrief meeneemt naar de eerste afspraak, zorg dan dat de volgende gegevens erop staan: Naam en AGB-code huisarts, GBGGZ, vermoeden van een DSM-V stoornis<\/div><\/fieldset><\/div><div id=\"wpforms-519-field_24-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"24\"><label class=\"wpforms-field-label\" for=\"wpforms-519-field_24\">Korte toelichting van de klachten waar je hulp bij zoekt  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-519-field_24\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][24]\" aria-errormessage=\"wpforms-519-field_24-error\" required><\/div><div id=\"wpforms-519-field_25-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"25\"><label class=\"wpforms-field-label\" for=\"wpforms-519-field_25\">Overige opmerkingen <\/label><input type=\"text\" id=\"wpforms-519-field_25\" class=\"wpforms-field-medium\" name=\"wpforms[fields][25]\" aria-errormessage=\"wpforms-519-field_25-error\" ><\/div><div id=\"wpforms-519-field_27-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"27\"><fieldset><legend class=\"wpforms-field-label\">Ik heb de behandelvoorwaarden gelezen en ik ga akkoord <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-519-field_27\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-519-field_27_1\" name=\"wpforms[fields][27][]\" value=\"akkoord\" aria-errormessage=\"wpforms-519-field_27_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-519-field_27_1\">akkoord<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-519-field_28-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"28\"><fieldset><legend class=\"wpforms-field-label\">Ik geef toestemming voor:  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-519-field_28\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-519-field_28_1\" name=\"wpforms[fields][28][]\" value=\"Uitwisseling van informatie tussen Praktijk de Buitenruimte en mijzelf via e-mail\" aria-errormessage=\"wpforms-519-field_28_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-519-field_28_1\">Uitwisseling van informatie tussen Praktijk de Buitenruimte en mijzelf via e-mail<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-519-field_28_2\" name=\"wpforms[fields][28][]\" value=\"Uitwisseling van informatie tussen Praktijk de Buitenruimte en de huisarts\/verwijzer\" aria-errormessage=\"wpforms-519-field_28_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-519-field_28_2\">Uitwisseling van informatie tussen Praktijk de Buitenruimte en de huisarts\/verwijzer<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-519-field_28_3\" name=\"wpforms[fields][28][]\" value=\"Geanonimiseerde uitwisseling van informatie tussen Praktijk de Buitenruimte en DIS\" aria-errormessage=\"wpforms-519-field_28_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-519-field_28_3\">Geanonimiseerde uitwisseling van informatie tussen Praktijk de Buitenruimte en DIS<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-519-field_28_4\" name=\"wpforms[fields][28][]\" value=\"Geen van bovenstaande opties\" aria-errormessage=\"wpforms-519-field_28_4-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-519-field_28_4\">Geen van bovenstaande opties<\/label><\/li><\/ul><\/fieldset><\/div><\/div><!-- .wpforms-field-container --><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"519\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/praktijkdebuitenruimte.nl\/index.php\/wp-json\/wp\/v2\/pages\/530\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-519\" class=\"wpforms-submit\" data-alt-text=\"Verzenden...\" data-submit-text=\"Verzend\" aria-live=\"assertive\" value=\"wpforms-submit\">Verzend<\/button><img decoding=\"async\" src=\"https:\/\/praktijkdebuitenruimte.nl\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Aan het laden\"><\/div><\/form><\/div>  <!-- .wpforms-container -->","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":130,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-530","page","type-page","status-publish","has-post-thumbnail","hentry"],"_links":{"self":[{"href":"https:\/\/praktijkdebuitenruimte.nl\/index.php\/wp-json\/wp\/v2\/pages\/530","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/praktijkdebuitenruimte.nl\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/praktijkdebuitenruimte.nl\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/praktijkdebuitenruimte.nl\/index.php\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/praktijkdebuitenruimte.nl\/index.php\/wp-json\/wp\/v2\/comments?post=530"}],"version-history":[{"count":2,"href":"https:\/\/praktijkdebuitenruimte.nl\/index.php\/wp-json\/wp\/v2\/pages\/530\/revisions"}],"predecessor-version":[{"id":533,"href":"https:\/\/praktijkdebuitenruimte.nl\/index.php\/wp-json\/wp\/v2\/pages\/530\/revisions\/533"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/praktijkdebuitenruimte.nl\/index.php\/wp-json\/wp\/v2\/media\/130"}],"wp:attachment":[{"href":"https:\/\/praktijkdebuitenruimte.nl\/index.php\/wp-json\/wp\/v2\/media?parent=530"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}