{"id":135,"date":"2025-08-22T11:29:21","date_gmt":"2025-08-22T09:29:21","guid":{"rendered":"https:\/\/drhenryocal.co.za\/?page_id=135"},"modified":"2025-08-23T17:43:31","modified_gmt":"2025-08-23T15:43:31","slug":"medical-documents","status":"publish","type":"page","link":"https:\/\/drhenryocal.co.za\/af\/medical-documents\/","title":{"rendered":"Medical Documents"},"content":{"rendered":"<p>Voltooi asseblief die onderstaande vorm voordat u by die praktyk opdaag vir u afspraak. Alle velde gemerk met 'n <span class=\"highlight\"><mark style=\"background-color:rgba(0, 0, 0, 0)\" class=\"has-inline-color has-theme-palette-2-color\">* (rooi asterisk)<\/mark><\/span> is verpligtend. Let asseblief daarop dat u die diensbepalings onderaan die vorm moet aanvaar en erken om hierdie vorm te kan indien en behandeling te ontvang. <\/p>\n\n\n\n<p class=\"has-theme-palette-2-color has-text-color has-link-color wp-elements-d2a5df79e35ee51d41b49ca92c65ac5a\"><strong>Indien u 'n fisiese vorm wil invul, arriveer asseblief ten minste 15 minute voor u eerste afspraak om dit te voltooi.<\/strong><\/p>\n\n\n\n<div class=\"forminator-guttenberg\"><div class=\"forminator-ui forminator-custom-form forminator-custom-form-142 forminator-design--default  forminator_ajax\" data-forminator-render=\"0\" data-form=\"forminator-module-142\" data-uid=\"6a330bfa8bd03\"><br\/><\/div><form\n\t\t\t\tid=\"forminator-module-142\"\n\t\t\t\tclass=\"forminator-ui forminator-custom-form forminator-custom-form-142 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=\"142\"\n\t\t\t\t data-color-option=\"theme\" data-design=\"default\" data-grid=\"open\" style=\"display: none;\"\n\t\t\t\tdata-uid=\"6a330bfa8bd03\" action=\"\"\n\t\t\t><div role=\"alert\" aria-live=\"polite\" class=\"forminator-response-message forminator-error\" aria-hidden=\"true\"><\/div><div class=\"forminator-row\"><div id=\"section-1\" class=\"forminator-field-section forminator-col forminator-col-12\"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Pasi\u00ebntbesonderhede<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-1\" class=\"forminator-field-name forminator-col forminator-col-12\"><div class=\"forminator-row forminator-no-margin\" data-multiple=\"true\"><div class=\"forminator-col forminator-col-md-6\"><div class=\"forminator-field\"><label for=\"forminator-field-142__field--name-1_6a330bfa8bd03\" id=\"forminator-field-142__field--name-1_6a330bfa8bd03-label\" class=\"forminator-label\">Titel<\/label><select name=\"name-1-prefix\" id=\"forminator-field-142__field--name-1_6a330bfa8bd03\" class=\"forminator-select2\" data-multi=\"1\" autocomplete=\"honorific-prefix\" aria-labelledby=\"forminator-field-142__field--name-1_6a330bfa8bd03-label\" data-default-value=\"\"><option value=\"Mr\" >Mr.<\/option><option value=\"Mrs\" >Mrs.<\/option><option value=\"Ms\" >Ms.<\/option><option value=\"Mx\" >Mx.<\/option><option value=\"Miss\" >Miss<\/option><option value=\"Dr\" >Dr.<\/option><option value=\"Prof\" >Prof.<\/option><\/select><\/div><\/div><div class=\"forminator-col forminator-col-md-6\"><div class=\"forminator-field\"><label for=\"forminator-field-first-name-1_6a330bfa8bd03\" id=\"forminator-field-first-name-1_6a330bfa8bd03-label\" class=\"forminator-label\">Voornaam <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-1-first-name\" placeholder=\"\" id=\"forminator-field-first-name-1_6a330bfa8bd03\" class=\"forminator-input\" aria-required=\"true\" data-multi=\"1\" autocomplete=\"given-name\" value=\"\" \/><\/div><\/div><div class=\"forminator-col forminator-col-md-6\"><div class=\"forminator-field\"><label for=\"forminator-field-last-name-1_6a330bfa8bd03\" id=\"forminator-field-last-name-1_6a330bfa8bd03-label\" class=\"forminator-label\">Van <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-1-last-name\" placeholder=\"\" id=\"forminator-field-last-name-1_6a330bfa8bd03\" class=\"forminator-input\" aria-required=\"true\" data-multi=\"1\" autocomplete=\"family-name\" value=\"\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"email-1\" class=\"forminator-field-email forminator-col forminator-col-12\"><div class=\"forminator-row-inside forminator-row-with-confirmation-email\"><div class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-email-1_6a330bfa8bd03\" id=\"forminator-field-email-1_6a330bfa8bd03-label\" class=\"forminator-label\">E-posadres <span class=\"forminator-required\">*<\/span><\/label><input type=\"email\" name=\"email-1\" value=\"\" placeholder=\"\" id=\"forminator-field-email-1_6a330bfa8bd03\" class=\"forminator-input forminator-email--field\" data-required=\"1\" aria-required=\"true\" autocomplete=\"email\" \/><\/div><\/div><div class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-confirm_email-1_6a330bfa8bd03\" id=\"forminator-field-confirm_email-1_6a330bfa8bd03-label\" class=\"forminator-label\">Bevestig E-posadres <span class=\"forminator-required\">*<\/span><\/label><input type=\"email\" name=\"confirm_email-1\" value=\"\" placeholder=\"Re-type Email Address\" id=\"forminator-field-confirm_email-1_6a330bfa8bd03\" class=\"forminator-input forminator-name--field\" data-required=\"1\" aria-required=\"true\" autocomplete=\"email\" \/><\/div><\/div><\/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_6a330bfa8bd03\" id=\"forminator-field-phone-1_6a330bfa8bd03-label\" class=\"forminator-label\">Telefoon <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"phone-1\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-1_6a330bfa8bd03\" class=\"forminator-input forminator-field--phone\" data-required=\"1\" aria-required=\"true\" autocomplete=\"off\" \/><\/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_6a330bfa8bd03\" id=\"forminator-field-text-1_6a330bfa8bd03-label\" class=\"forminator-label\">ID Nommer <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-1\" value=\"\" placeholder=\"\" id=\"forminator-field-text-1_6a330bfa8bd03\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-1\" class=\"forminator-field-date forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-date-1-picker_6a330bfa8bd03\" id=\"forminator-field-date-1-picker_6a330bfa8bd03-label\" class=\"forminator-label\">Geboortedatum <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-1\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-1-picker_6a330bfa8bd03\" 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=\"2026\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"2026-06-17\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"number-2\" class=\"forminator-field-number forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-number-2_6a330bfa8bd03\" id=\"forminator-field-number-2_6a330bfa8bd03-label\" class=\"forminator-label\">Ouderdom <span class=\"forminator-required\">*<\/span><\/label><input name=\"number-2\" value=\"\" placeholder=\"\" id=\"forminator-field-number-2_6a330bfa8bd03\" class=\"forminator-input forminator-number--field\" inputmode=\"decimal\" data-required=\"1\" data-decimals=\"0\" aria-required=\"true\" data-inputmask=\"&#039;groupSeparator&#039;: &#039;&#039;, &#039;radixPoint&#039;: &#039;&#039;, &#039;digits&#039;: &#039;0&#039;\" data-hidden-behavior=\"zero\" type=\"number\" step=\"any\" min=\"1\" max=\"150\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-1\" class=\"forminator-field-address forminator-col forminator-col-12\"><div class=\"forminator-row\"><div id=\"address-1-street_address\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-street_address_6a330bfa8bd03\" id=\"forminator-field-address-1-street_address_6a330bfa8bd03-label\" class=\"forminator-label\">Straatadres<\/label><input type=\"text\" name=\"address-1-street_address\" placeholder=\"\" id=\"forminator-field-address-1-street_address_6a330bfa8bd03\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" autocomplete=\"address-line1\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-1-address_line\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-address_line_6a330bfa8bd03\" id=\"forminator-field-address-1-address_line_6a330bfa8bd03-label\" class=\"forminator-label\">Huisnommer, woonstel, suite, ens.<\/label><input type=\"text\" name=\"address-1-address_line\" placeholder=\"\" id=\"forminator-field-address-1-address_line_6a330bfa8bd03\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" autocomplete=\"address-line2\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\" data-multiple=\"false\"><div id=\"address-1-city\" class=\"forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-city_6a330bfa8bd03\" id=\"forminator-field-address-1-city_6a330bfa8bd03-label\" class=\"forminator-label\">Stad\/Dorp<\/label><input type=\"text\" name=\"address-1-city\" placeholder=\"\" id=\"forminator-field-address-1-city_6a330bfa8bd03\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" autocomplete=\"address-level2\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\" data-multiple=\"false\"><div id=\"address-1-zip\" class=\"forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-zip_6a330bfa8bd03\" id=\"forminator-field-address-1-zip_6a330bfa8bd03-label\" class=\"forminator-label\">Poskode<\/label><input type=\"text\" name=\"address-1-zip\" placeholder=\"\" id=\"forminator-field-address-1-zip_6a330bfa8bd03\" class=\"forminator-input\" autocomplete=\"postal-code\" value=\"\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-4\" class=\"forminator-field-section forminator-col forminator-col-12\"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Naasbestaande<\/h2><h3 class=\"forminator-subtitle\">Ook ouer of wettige voog indien pasi\u00ebnt onder 18 is<\/h3><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-3\" class=\"forminator-field-name forminator-col forminator-col-12\"><div class=\"forminator-row forminator-no-margin\" data-multiple=\"true\"><div class=\"forminator-col forminator-col-md-6\"><div class=\"forminator-field\"><label for=\"forminator-field-142__field--name-3_6a330bfa8bd03\" id=\"forminator-field-142__field--name-3_6a330bfa8bd03-label\" class=\"forminator-label\">Titel<\/label><select name=\"name-3-prefix\" id=\"forminator-field-142__field--name-3_6a330bfa8bd03\" class=\"forminator-select2\" data-multi=\"1\" autocomplete=\"honorific-prefix\" aria-labelledby=\"forminator-field-142__field--name-3_6a330bfa8bd03-label\" data-default-value=\"\"><option value=\"Mr\" >Mr.<\/option><option value=\"Mrs\" >Mrs.<\/option><option value=\"Ms\" >Ms.<\/option><option value=\"Mx\" >Mx.<\/option><option value=\"Miss\" >Miss<\/option><option value=\"Dr\" >Dr.<\/option><option value=\"Prof\" >Prof.<\/option><\/select><\/div><\/div><div class=\"forminator-col forminator-col-md-6\"><div class=\"forminator-field\"><label for=\"forminator-field-first-name-3_6a330bfa8bd03\" id=\"forminator-field-first-name-3_6a330bfa8bd03-label\" class=\"forminator-label\">Voornaam<\/label><input type=\"text\" name=\"name-3-first-name\" placeholder=\"\" id=\"forminator-field-first-name-3_6a330bfa8bd03\" class=\"forminator-input\" aria-required=\"false\" data-multi=\"1\" autocomplete=\"given-name\" value=\"\" \/><\/div><\/div><div class=\"forminator-col forminator-col-md-6\"><div class=\"forminator-field\"><label for=\"forminator-field-last-name-3_6a330bfa8bd03\" id=\"forminator-field-last-name-3_6a330bfa8bd03-label\" class=\"forminator-label\">Van<\/label><input type=\"text\" name=\"name-3-last-name\" placeholder=\"\" id=\"forminator-field-last-name-3_6a330bfa8bd03\" class=\"forminator-input\" aria-required=\"false\" data-multi=\"1\" autocomplete=\"family-name\" value=\"\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"phone-3\" class=\"forminator-field-phone forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-phone-3_6a330bfa8bd03\" id=\"forminator-field-phone-3_6a330bfa8bd03-label\" class=\"forminator-label\">Telefoon<\/label><input type=\"text\" name=\"phone-3\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-3_6a330bfa8bd03\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"email-3\" class=\"forminator-field-email forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-email-3_6a330bfa8bd03\" id=\"forminator-field-email-3_6a330bfa8bd03-label\" class=\"forminator-label\">E-posadres<\/label><input type=\"email\" name=\"email-3\" value=\"\" placeholder=\"\" id=\"forminator-field-email-3_6a330bfa8bd03\" class=\"forminator-input forminator-email--field\" data-required=\"\" aria-required=\"false\" autocomplete=\"email\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-4\" class=\"forminator-field-text forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-text-4_6a330bfa8bd03\" id=\"forminator-field-text-4_6a330bfa8bd03-label\" class=\"forminator-label\">Verhouding<\/label><input type=\"text\" name=\"text-4\" value=\"\" placeholder=\"\" id=\"forminator-field-text-4_6a330bfa8bd03\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/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\">Prim\u00eare Rekeninghouer<\/h2><h3 class=\"forminator-subtitle\">Besonderhede van persoon verantwoordelik vir u rekening (los leeg indien dieselfde as hierbo)<\/h3><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-2\" class=\"forminator-field-name forminator-col forminator-col-12\"><div class=\"forminator-row forminator-no-margin\" data-multiple=\"true\"><div class=\"forminator-col forminator-col-md-6\"><div class=\"forminator-field\"><label for=\"forminator-field-142__field--name-2_6a330bfa8bd03\" id=\"forminator-field-142__field--name-2_6a330bfa8bd03-label\" class=\"forminator-label\">Titel<\/label><select name=\"name-2-prefix\" id=\"forminator-field-142__field--name-2_6a330bfa8bd03\" class=\"forminator-select2\" data-multi=\"1\" autocomplete=\"honorific-prefix\" aria-labelledby=\"forminator-field-142__field--name-2_6a330bfa8bd03-label\" data-default-value=\"\"><option value=\"Mr\" >Mr.<\/option><option value=\"Mrs\" >Mrs.<\/option><option value=\"Ms\" >Ms.<\/option><option value=\"Mx\" >Mx.<\/option><option value=\"Miss\" >Miss<\/option><option value=\"Dr\" >Dr.<\/option><option value=\"Prof\" >Prof.<\/option><\/select><\/div><\/div><div class=\"forminator-col forminator-col-md-6\"><div class=\"forminator-field\"><label for=\"forminator-field-first-name-2_6a330bfa8bd03\" id=\"forminator-field-first-name-2_6a330bfa8bd03-label\" class=\"forminator-label\">Voornaam<\/label><input type=\"text\" name=\"name-2-first-name\" placeholder=\"\" id=\"forminator-field-first-name-2_6a330bfa8bd03\" class=\"forminator-input\" aria-required=\"false\" data-multi=\"1\" autocomplete=\"given-name\" value=\"\" \/><\/div><\/div><div class=\"forminator-col forminator-col-md-6\"><div class=\"forminator-field\"><label for=\"forminator-field-last-name-2_6a330bfa8bd03\" id=\"forminator-field-last-name-2_6a330bfa8bd03-label\" class=\"forminator-label\">Van<\/label><input type=\"text\" name=\"name-2-last-name\" placeholder=\"\" id=\"forminator-field-last-name-2_6a330bfa8bd03\" class=\"forminator-input\" aria-required=\"false\" data-multi=\"1\" autocomplete=\"family-name\" value=\"\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"email-2\" class=\"forminator-field-email forminator-col forminator-col-12\"><div class=\"forminator-row-inside forminator-row-with-confirmation-email\"><div class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-email-2_6a330bfa8bd03\" id=\"forminator-field-email-2_6a330bfa8bd03-label\" class=\"forminator-label\">E-posadres<\/label><input type=\"email\" name=\"email-2\" value=\"\" placeholder=\"\" id=\"forminator-field-email-2_6a330bfa8bd03\" class=\"forminator-input forminator-email--field\" data-required=\"\" aria-required=\"false\" autocomplete=\"email\" \/><\/div><\/div><div class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-confirm_email-2_6a330bfa8bd03\" id=\"forminator-field-confirm_email-2_6a330bfa8bd03-label\" class=\"forminator-label\">Bevestig E-posadres<\/label><input type=\"email\" name=\"confirm_email-2\" value=\"\" placeholder=\"Re-type Email Address\" id=\"forminator-field-confirm_email-2_6a330bfa8bd03\" class=\"forminator-input forminator-name--field\" data-required=\"\" aria-required=\"false\" autocomplete=\"email\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"phone-2\" class=\"forminator-field-phone forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-phone-2_6a330bfa8bd03\" id=\"forminator-field-phone-2_6a330bfa8bd03-label\" class=\"forminator-label\">Telefoon<\/label><input type=\"text\" name=\"phone-2\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-2_6a330bfa8bd03\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-2\" class=\"forminator-field-text forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-text-2_6a330bfa8bd03\" id=\"forminator-field-text-2_6a330bfa8bd03-label\" class=\"forminator-label\">ID Nommer<\/label><input type=\"text\" name=\"text-2\" value=\"\" placeholder=\"\" id=\"forminator-field-text-2_6a330bfa8bd03\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"number-1\" class=\"forminator-field-number forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-number-1_6a330bfa8bd03\" id=\"forminator-field-number-1_6a330bfa8bd03-label\" class=\"forminator-label\">Ouderdom<\/label><input name=\"number-1\" value=\"\" placeholder=\"\" id=\"forminator-field-number-1_6a330bfa8bd03\" class=\"forminator-input forminator-number--field\" inputmode=\"decimal\" data-required=\"\" data-decimals=\"0\" aria-required=\"false\" data-inputmask=\"&#039;groupSeparator&#039;: &#039;&#039;, &#039;radixPoint&#039;: &#039;&#039;, &#039;digits&#039;: &#039;0&#039;\" data-hidden-behavior=\"zero\" type=\"number\" step=\"any\" min=\"1\" max=\"150\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-2\" class=\"forminator-field-address forminator-col forminator-col-12\"><div class=\"forminator-row\"><div id=\"address-2-street_address\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-2-street_address_6a330bfa8bd03\" id=\"forminator-field-address-2-street_address_6a330bfa8bd03-label\" class=\"forminator-label\">Straatadres<\/label><input type=\"text\" name=\"address-2-street_address\" placeholder=\"\" id=\"forminator-field-address-2-street_address_6a330bfa8bd03\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" autocomplete=\"address-line1\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\" data-multiple=\"true\"><div id=\"address-2-city\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-address-2-city_6a330bfa8bd03\" id=\"forminator-field-address-2-city_6a330bfa8bd03-label\" class=\"forminator-label\">Stad\/Dorp<\/label><input type=\"text\" name=\"address-2-city\" placeholder=\"\" id=\"forminator-field-address-2-city_6a330bfa8bd03\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" autocomplete=\"address-level2\" value=\"\" \/><\/div><\/div><div id=\"address-2-state\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-address-2-state_6a330bfa8bd03\" id=\"forminator-field-address-2-state_6a330bfa8bd03-label\" class=\"forminator-label\">State\/Province<\/label><input type=\"text\" name=\"address-2-state\" placeholder=\"\" id=\"forminator-field-address-2-state_6a330bfa8bd03\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" autocomplete=\"address-level1\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\" data-multiple=\"false\"><div id=\"address-2-zip\" class=\"forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-address-2-zip_6a330bfa8bd03\" id=\"forminator-field-address-2-zip_6a330bfa8bd03-label\" class=\"forminator-label\">Poskode<\/label><input type=\"text\" name=\"address-2-zip\" placeholder=\"\" id=\"forminator-field-address-2-zip_6a330bfa8bd03\" class=\"forminator-input\" autocomplete=\"postal-code\" value=\"\" \/><\/div><\/div><\/div><\/div><\/div><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\">Mediese Fonds Besonderhede<\/h2><h3 class=\"forminator-subtitle\">Hierdie inligting is nie verpligtend nie, maar nuttig as u enige rekeninge van u mediese fonds wil dek.<\/h3><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-1\" class=\"forminator-field-textarea forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-1_6a330bfa8bd03\" id=\"forminator-field-textarea-1_6a330bfa8bd03-label\" class=\"forminator-label\">Mediese Fonds Naam<\/label><textarea name=\"textarea-1\" placeholder=\"\" id=\"forminator-field-textarea-1_6a330bfa8bd03\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-3\" class=\"forminator-field-textarea forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-3_6a330bfa8bd03\" id=\"forminator-field-textarea-3_6a330bfa8bd03-label\" class=\"forminator-label\">Plan Naam<\/label><textarea name=\"textarea-3\" placeholder=\"\" id=\"forminator-field-textarea-3_6a330bfa8bd03\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/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_6a330bfa8bd03\" id=\"forminator-field-text-3_6a330bfa8bd03-label\" class=\"forminator-label\">Hooflid<\/label><input type=\"text\" name=\"text-3\" value=\"\" placeholder=\"\" id=\"forminator-field-text-3_6a330bfa8bd03\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-2\" class=\"forminator-field-textarea forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-2_6a330bfa8bd03\" id=\"forminator-field-textarea-2_6a330bfa8bd03-label\" class=\"forminator-label\">Mediese Fonds Nommer<\/label><textarea name=\"textarea-2\" placeholder=\"\" id=\"forminator-field-textarea-2_6a330bfa8bd03\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-5\" class=\"forminator-field-section forminator-col forminator-col-12\"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Mediese Geskiedenis<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-4\" class=\"forminator-field-name forminator-col forminator-col-12\"><div class=\"forminator-row forminator-no-margin\" data-multiple=\"true\"><div class=\"forminator-col forminator-col-md-6\"><div class=\"forminator-field\"><label for=\"forminator-field-first-name-4_6a330bfa8bd03\" id=\"forminator-field-first-name-4_6a330bfa8bd03-label\" class=\"forminator-label\">Huisdokter Voornaam <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-4-first-name\" placeholder=\"\" id=\"forminator-field-first-name-4_6a330bfa8bd03\" class=\"forminator-input\" aria-required=\"true\" data-multi=\"1\" autocomplete=\"given-name\" value=\"\" \/><\/div><\/div><div class=\"forminator-col forminator-col-md-6\"><div class=\"forminator-field\"><label for=\"forminator-field-last-name-4_6a330bfa8bd03\" id=\"forminator-field-last-name-4_6a330bfa8bd03-label\" class=\"forminator-label\">Huisdokter Van <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-4-last-name\" placeholder=\"\" id=\"forminator-field-last-name-4_6a330bfa8bd03\" class=\"forminator-input\" aria-required=\"true\" data-multi=\"1\" autocomplete=\"family-name\" value=\"\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"phone-4\" class=\"forminator-field-phone forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-phone-4_6a330bfa8bd03\" id=\"forminator-field-phone-4_6a330bfa8bd03-label\" class=\"forminator-label\">Nommer van u huisdokter<\/label><input type=\"text\" name=\"phone-4\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-4_6a330bfa8bd03\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" \/><\/div><\/div><div id=\"email-4\" class=\"forminator-field-email forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-email-4_6a330bfa8bd03\" id=\"forminator-field-email-4_6a330bfa8bd03-label\" class=\"forminator-label\">E-pos van u huisdokter<\/label><input type=\"email\" name=\"email-4\" value=\"\" placeholder=\"\" id=\"forminator-field-email-4_6a330bfa8bd03\" class=\"forminator-input forminator-email--field\" data-required=\"\" aria-required=\"false\" autocomplete=\"email\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-1\" class=\"forminator-field-checkbox forminator-col forminator-col-12\"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-1-6a330bfa8bd03-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-1-6a330bfa8bd03-label\" class=\"forminator-label\">Het jy of het jy enige van die volgende ervaar?<\/span><label id=\"forminator-field-checkbox-1-1-6a330bfa8bd03-label\" for=\"forminator-field-checkbox-1-1-6a330bfa8bd03\" class=\"forminator-checkbox\" title=\"Abnormal Bleeding\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"one\" id=\"forminator-field-checkbox-1-1-6a330bfa8bd03\" aria-labelledby=\"forminator-field-checkbox-1-1-6a330bfa8bd03-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Abnormal Bleeding<\/span><\/label><label id=\"forminator-field-checkbox-1-2-6a330bfa8bd03-label\" for=\"forminator-field-checkbox-1-2-6a330bfa8bd03\" class=\"forminator-checkbox\" title=\"Anaemia\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"two\" id=\"forminator-field-checkbox-1-2-6a330bfa8bd03\" aria-labelledby=\"forminator-field-checkbox-1-2-6a330bfa8bd03-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Anaemia<\/span><\/label><label id=\"forminator-field-checkbox-1-3-6a330bfa8bd03-label\" for=\"forminator-field-checkbox-1-3-6a330bfa8bd03\" class=\"forminator-checkbox\" title=\"Artificial Bones\/Joints\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"three\" id=\"forminator-field-checkbox-1-3-6a330bfa8bd03\" aria-labelledby=\"forminator-field-checkbox-1-3-6a330bfa8bd03-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Artificial Bones\/Joints<\/span><\/label><label id=\"forminator-field-checkbox-1-4-6a330bfa8bd03-label\" for=\"forminator-field-checkbox-1-4-6a330bfa8bd03\" class=\"forminator-checkbox\" title=\"Artificial Valves\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"four\" id=\"forminator-field-checkbox-1-4-6a330bfa8bd03\" aria-labelledby=\"forminator-field-checkbox-1-4-6a330bfa8bd03-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Artificial Valves<\/span><\/label><label id=\"forminator-field-checkbox-1-5-6a330bfa8bd03-label\" for=\"forminator-field-checkbox-1-5-6a330bfa8bd03\" class=\"forminator-checkbox\" title=\"Asthma\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"five\" id=\"forminator-field-checkbox-1-5-6a330bfa8bd03\" aria-labelledby=\"forminator-field-checkbox-1-5-6a330bfa8bd03-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Asthma<\/span><\/label><label id=\"forminator-field-checkbox-1-6-6a330bfa8bd03-label\" for=\"forminator-field-checkbox-1-6-6a330bfa8bd03\" class=\"forminator-checkbox\" title=\"Angina\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"six\" id=\"forminator-field-checkbox-1-6-6a330bfa8bd03\" aria-labelledby=\"forminator-field-checkbox-1-6-6a330bfa8bd03-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Angina<\/span><\/label><label id=\"forminator-field-checkbox-1-7-6a330bfa8bd03-label\" for=\"forminator-field-checkbox-1-7-6a330bfa8bd03\" class=\"forminator-checkbox\" title=\"Breathing Problems\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"seven\" id=\"forminator-field-checkbox-1-7-6a330bfa8bd03\" aria-labelledby=\"forminator-field-checkbox-1-7-6a330bfa8bd03-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Breathing Problems<\/span><\/label><label id=\"forminator-field-checkbox-1-8-6a330bfa8bd03-label\" for=\"forminator-field-checkbox-1-8-6a330bfa8bd03\" class=\"forminator-checkbox\" title=\"Cancer\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"eight\" id=\"forminator-field-checkbox-1-8-6a330bfa8bd03\" aria-labelledby=\"forminator-field-checkbox-1-8-6a330bfa8bd03-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Cancer<\/span><\/label><label id=\"forminator-field-checkbox-1-9-6a330bfa8bd03-label\" for=\"forminator-field-checkbox-1-9-6a330bfa8bd03\" class=\"forminator-checkbox\" title=\"Cold sore\/Fever Blisters\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"nine\" id=\"forminator-field-checkbox-1-9-6a330bfa8bd03\" aria-labelledby=\"forminator-field-checkbox-1-9-6a330bfa8bd03-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Cold sore\/Fever Blisters<\/span><\/label><label id=\"forminator-field-checkbox-1-10-6a330bfa8bd03-label\" for=\"forminator-field-checkbox-1-10-6a330bfa8bd03\" class=\"forminator-checkbox\" title=\"Diabetes\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"ten\" id=\"forminator-field-checkbox-1-10-6a330bfa8bd03\" aria-labelledby=\"forminator-field-checkbox-1-10-6a330bfa8bd03-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Diabetes<\/span><\/label><label id=\"forminator-field-checkbox-1-11-6a330bfa8bd03-label\" for=\"forminator-field-checkbox-1-11-6a330bfa8bd03\" class=\"forminator-checkbox\" title=\"Depressive Illness\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"eleven\" id=\"forminator-field-checkbox-1-11-6a330bfa8bd03\" aria-labelledby=\"forminator-field-checkbox-1-11-6a330bfa8bd03-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Depressive Illness<\/span><\/label><label id=\"forminator-field-checkbox-1-12-6a330bfa8bd03-label\" for=\"forminator-field-checkbox-1-12-6a330bfa8bd03\" class=\"forminator-checkbox\" title=\"Emphysema\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"twelve\" id=\"forminator-field-checkbox-1-12-6a330bfa8bd03\" aria-labelledby=\"forminator-field-checkbox-1-12-6a330bfa8bd03-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Emphysema<\/span><\/label><label id=\"forminator-field-checkbox-1-13-6a330bfa8bd03-label\" for=\"forminator-field-checkbox-1-13-6a330bfa8bd03\" class=\"forminator-checkbox\" title=\"Epilepsy\/Seizures\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"thirteen\" id=\"forminator-field-checkbox-1-13-6a330bfa8bd03\" aria-labelledby=\"forminator-field-checkbox-1-13-6a330bfa8bd03-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Epilepsy\/Seizures<\/span><\/label><label id=\"forminator-field-checkbox-1-14-6a330bfa8bd03-label\" for=\"forminator-field-checkbox-1-14-6a330bfa8bd03\" class=\"forminator-checkbox\" title=\"Fainting Spells\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"fourteen\" id=\"forminator-field-checkbox-1-14-6a330bfa8bd03\" aria-labelledby=\"forminator-field-checkbox-1-14-6a330bfa8bd03-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Fainting Spells<\/span><\/label><label id=\"forminator-field-checkbox-1-15-6a330bfa8bd03-label\" for=\"forminator-field-checkbox-1-15-6a330bfa8bd03\" class=\"forminator-checkbox\" title=\"Glaucoma\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"fifteen\" id=\"forminator-field-checkbox-1-15-6a330bfa8bd03\" aria-labelledby=\"forminator-field-checkbox-1-15-6a330bfa8bd03-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Glaucoma<\/span><\/label><label id=\"forminator-field-checkbox-1-16-6a330bfa8bd03-label\" for=\"forminator-field-checkbox-1-16-6a330bfa8bd03\" class=\"forminator-checkbox\" title=\"Headaches\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"sixteen\" id=\"forminator-field-checkbox-1-16-6a330bfa8bd03\" aria-labelledby=\"forminator-field-checkbox-1-16-6a330bfa8bd03-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Headaches<\/span><\/label><label id=\"forminator-field-checkbox-1-17-6a330bfa8bd03-label\" for=\"forminator-field-checkbox-1-17-6a330bfa8bd03\" class=\"forminator-checkbox\" title=\"Heart Disorder\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"seventeen\" id=\"forminator-field-checkbox-1-17-6a330bfa8bd03\" aria-labelledby=\"forminator-field-checkbox-1-17-6a330bfa8bd03-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Heart Disorder<\/span><\/label><label id=\"forminator-field-checkbox-1-18-6a330bfa8bd03-label\" for=\"forminator-field-checkbox-1-18-6a330bfa8bd03\" class=\"forminator-checkbox\" title=\"Hay fever\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"eighteen\" id=\"forminator-field-checkbox-1-18-6a330bfa8bd03\" aria-labelledby=\"forminator-field-checkbox-1-18-6a330bfa8bd03-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Hay fever<\/span><\/label><label id=\"forminator-field-checkbox-1-19-6a330bfa8bd03-label\" for=\"forminator-field-checkbox-1-19-6a330bfa8bd03\" class=\"forminator-checkbox\" title=\"Haemophilia\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"nineteen\" id=\"forminator-field-checkbox-1-19-6a330bfa8bd03\" aria-labelledby=\"forminator-field-checkbox-1-19-6a330bfa8bd03-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Haemophilia<\/span><\/label><label id=\"forminator-field-checkbox-1-20-6a330bfa8bd03-label\" for=\"forminator-field-checkbox-1-20-6a330bfa8bd03\" class=\"forminator-checkbox\" title=\"Hepatitis\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"twenty\" id=\"forminator-field-checkbox-1-20-6a330bfa8bd03\" aria-labelledby=\"forminator-field-checkbox-1-20-6a330bfa8bd03-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Hepatitis<\/span><\/label><label id=\"forminator-field-checkbox-1-21-6a330bfa8bd03-label\" for=\"forminator-field-checkbox-1-21-6a330bfa8bd03\" class=\"forminator-checkbox\" title=\"Herpes\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"twenty-one\" id=\"forminator-field-checkbox-1-21-6a330bfa8bd03\" aria-labelledby=\"forminator-field-checkbox-1-21-6a330bfa8bd03-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Herpes<\/span><\/label><label id=\"forminator-field-checkbox-1-22-6a330bfa8bd03-label\" for=\"forminator-field-checkbox-1-22-6a330bfa8bd03\" class=\"forminator-checkbox\" title=\"High Blood Pressure\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"twenty-two\" id=\"forminator-field-checkbox-1-22-6a330bfa8bd03\" aria-labelledby=\"forminator-field-checkbox-1-22-6a330bfa8bd03-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">High Blood Pressure<\/span><\/label><label id=\"forminator-field-checkbox-1-23-6a330bfa8bd03-label\" for=\"forminator-field-checkbox-1-23-6a330bfa8bd03\" class=\"forminator-checkbox\" title=\"HIV+\/AIDS\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"twenty-three\" id=\"forminator-field-checkbox-1-23-6a330bfa8bd03\" aria-labelledby=\"forminator-field-checkbox-1-23-6a330bfa8bd03-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">HIV+\/AIDS<\/span><\/label><label id=\"forminator-field-checkbox-1-24-6a330bfa8bd03-label\" for=\"forminator-field-checkbox-1-24-6a330bfa8bd03\" class=\"forminator-checkbox\" title=\"Kidney Problems\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"twenty-four\" id=\"forminator-field-checkbox-1-24-6a330bfa8bd03\" aria-labelledby=\"forminator-field-checkbox-1-24-6a330bfa8bd03-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Kidney Problems<\/span><\/label><label id=\"forminator-field-checkbox-1-25-6a330bfa8bd03-label\" for=\"forminator-field-checkbox-1-25-6a330bfa8bd03\" class=\"forminator-checkbox\" title=\"Lung Disease\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"twenty-five\" id=\"forminator-field-checkbox-1-25-6a330bfa8bd03\" aria-labelledby=\"forminator-field-checkbox-1-25-6a330bfa8bd03-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Lung Disease<\/span><\/label><label id=\"forminator-field-checkbox-1-26-6a330bfa8bd03-label\" for=\"forminator-field-checkbox-1-26-6a330bfa8bd03\" class=\"forminator-checkbox\" title=\"Liver Disease\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"twenty-six\" id=\"forminator-field-checkbox-1-26-6a330bfa8bd03\" aria-labelledby=\"forminator-field-checkbox-1-26-6a330bfa8bd03-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Liver Disease<\/span><\/label><label id=\"forminator-field-checkbox-1-27-6a330bfa8bd03-label\" for=\"forminator-field-checkbox-1-27-6a330bfa8bd03\" class=\"forminator-checkbox\" title=\"Lupus\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"twenty-seven\" id=\"forminator-field-checkbox-1-27-6a330bfa8bd03\" aria-labelledby=\"forminator-field-checkbox-1-27-6a330bfa8bd03-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Lupus<\/span><\/label><label id=\"forminator-field-checkbox-1-28-6a330bfa8bd03-label\" for=\"forminator-field-checkbox-1-28-6a330bfa8bd03\" class=\"forminator-checkbox\" title=\"Osteoporosis\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"twenty-eight\" id=\"forminator-field-checkbox-1-28-6a330bfa8bd03\" aria-labelledby=\"forminator-field-checkbox-1-28-6a330bfa8bd03-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Osteoporosis<\/span><\/label><label id=\"forminator-field-checkbox-1-29-6a330bfa8bd03-label\" for=\"forminator-field-checkbox-1-29-6a330bfa8bd03\" class=\"forminator-checkbox\" title=\"Pacemaker\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"twenty-nine\" id=\"forminator-field-checkbox-1-29-6a330bfa8bd03\" aria-labelledby=\"forminator-field-checkbox-1-29-6a330bfa8bd03-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Pacemaker<\/span><\/label><label id=\"forminator-field-checkbox-1-30-6a330bfa8bd03-label\" for=\"forminator-field-checkbox-1-30-6a330bfa8bd03\" class=\"forminator-checkbox\" title=\"Pain in Jaw Joints\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"thirty\" id=\"forminator-field-checkbox-1-30-6a330bfa8bd03\" aria-labelledby=\"forminator-field-checkbox-1-30-6a330bfa8bd03-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Pain in Jaw Joints<\/span><\/label><label id=\"forminator-field-checkbox-1-31-6a330bfa8bd03-label\" for=\"forminator-field-checkbox-1-31-6a330bfa8bd03\" class=\"forminator-checkbox\" title=\"Rheumatic Fever\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"thirty-one\" id=\"forminator-field-checkbox-1-31-6a330bfa8bd03\" aria-labelledby=\"forminator-field-checkbox-1-31-6a330bfa8bd03-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Rheumatic Fever<\/span><\/label><label id=\"forminator-field-checkbox-1-32-6a330bfa8bd03-label\" for=\"forminator-field-checkbox-1-32-6a330bfa8bd03\" class=\"forminator-checkbox\" title=\"Seizures\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"thirty-two\" id=\"forminator-field-checkbox-1-32-6a330bfa8bd03\" aria-labelledby=\"forminator-field-checkbox-1-32-6a330bfa8bd03-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Seizures<\/span><\/label><label id=\"forminator-field-checkbox-1-33-6a330bfa8bd03-label\" for=\"forminator-field-checkbox-1-33-6a330bfa8bd03\" class=\"forminator-checkbox\" title=\"Sinus Trouble\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"thirty-three\" id=\"forminator-field-checkbox-1-33-6a330bfa8bd03\" aria-labelledby=\"forminator-field-checkbox-1-33-6a330bfa8bd03-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Sinus Trouble<\/span><\/label><label id=\"forminator-field-checkbox-1-34-6a330bfa8bd03-label\" for=\"forminator-field-checkbox-1-34-6a330bfa8bd03\" class=\"forminator-checkbox\" title=\"Intestinal Disease\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"thirty-four\" id=\"forminator-field-checkbox-1-34-6a330bfa8bd03\" aria-labelledby=\"forminator-field-checkbox-1-34-6a330bfa8bd03-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Intestinal Disease<\/span><\/label><label id=\"forminator-field-checkbox-1-35-6a330bfa8bd03-label\" for=\"forminator-field-checkbox-1-35-6a330bfa8bd03\" class=\"forminator-checkbox\" title=\"Stroke\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"thirty-five\" id=\"forminator-field-checkbox-1-35-6a330bfa8bd03\" aria-labelledby=\"forminator-field-checkbox-1-35-6a330bfa8bd03-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Stroke<\/span><\/label><label id=\"forminator-field-checkbox-1-36-6a330bfa8bd03-label\" for=\"forminator-field-checkbox-1-36-6a330bfa8bd03\" class=\"forminator-checkbox\" title=\"Tobacco Use (Smoke)\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"thirty-six\" id=\"forminator-field-checkbox-1-36-6a330bfa8bd03\" aria-labelledby=\"forminator-field-checkbox-1-36-6a330bfa8bd03-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Tobacco Use (Smoke)<\/span><\/label><label id=\"forminator-field-checkbox-1-37-6a330bfa8bd03-label\" for=\"forminator-field-checkbox-1-37-6a330bfa8bd03\" class=\"forminator-checkbox\" title=\"Tuberculosis (TB)\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"thirty-seven\" id=\"forminator-field-checkbox-1-37-6a330bfa8bd03\" aria-labelledby=\"forminator-field-checkbox-1-37-6a330bfa8bd03-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Tuberculosis (TB)<\/span><\/label><label id=\"forminator-field-checkbox-1-38-6a330bfa8bd03-label\" for=\"forminator-field-checkbox-1-38-6a330bfa8bd03\" class=\"forminator-checkbox\" title=\"Tumours\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"thirty-eight\" id=\"forminator-field-checkbox-1-38-6a330bfa8bd03\" aria-labelledby=\"forminator-field-checkbox-1-38-6a330bfa8bd03-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Tumours<\/span><\/label><label id=\"forminator-field-checkbox-1-39-6a330bfa8bd03-label\" for=\"forminator-field-checkbox-1-39-6a330bfa8bd03\" class=\"forminator-checkbox\" title=\"Ulcers\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"thirty-nine\" id=\"forminator-field-checkbox-1-39-6a330bfa8bd03\" aria-labelledby=\"forminator-field-checkbox-1-39-6a330bfa8bd03-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Ulcers<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-4\" class=\"forminator-field-textarea forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-4_6a330bfa8bd03\" id=\"forminator-field-textarea-4_6a330bfa8bd03-label\" class=\"forminator-label\">Lys asseblief enige ernstige mediese toestand(e) wat u ervaar het:<\/label><textarea name=\"textarea-4\" placeholder=\"\" id=\"forminator-field-textarea-4_6a330bfa8bd03\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-5\" class=\"forminator-field-textarea forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-5_6a330bfa8bd03\" id=\"forminator-field-textarea-5_6a330bfa8bd03-label\" class=\"forminator-label\">Lys asseblief enige medikasie wat u tans neem:<\/label><textarea name=\"textarea-5\" placeholder=\"\" id=\"forminator-field-textarea-5_6a330bfa8bd03\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-6\" class=\"forminator-field-textarea forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-6_6a330bfa8bd03\" id=\"forminator-field-textarea-6_6a330bfa8bd03-label\" class=\"forminator-label\">Enige allergie\u00eb waarvan u bewus is?<\/label><textarea name=\"textarea-6\" placeholder=\"\" id=\"forminator-field-textarea-6_6a330bfa8bd03\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-6\" class=\"forminator-field-section forminator-col forminator-col-12\"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Vir Vroue<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-2\" class=\"forminator-field-checkbox forminator-col forminator-col-12\"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-2-6a330bfa8bd03-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-2-6a330bfa8bd03-label\" class=\"forminator-label\">Is jy swanger of vermoed jy dat jy swanger is?<\/span><label id=\"forminator-field-checkbox-2-1-6a330bfa8bd03-label\" for=\"forminator-field-checkbox-2-1-6a330bfa8bd03\" class=\"forminator-checkbox\" title=\"Ja\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"one\" id=\"forminator-field-checkbox-2-1-6a330bfa8bd03\" aria-labelledby=\"forminator-field-checkbox-2-1-6a330bfa8bd03-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Ja<\/span><\/label><label id=\"forminator-field-checkbox-2-2-6a330bfa8bd03-label\" for=\"forminator-field-checkbox-2-2-6a330bfa8bd03\" class=\"forminator-checkbox\" title=\"Nee\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"two\" id=\"forminator-field-checkbox-2-2-6a330bfa8bd03\" aria-labelledby=\"forminator-field-checkbox-2-2-6a330bfa8bd03-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Nee<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-5\" class=\"forminator-field-text forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-text-5_6a330bfa8bd03\" id=\"forminator-field-text-5_6a330bfa8bd03-label\" class=\"forminator-label\">Weeks pregnant<\/label><input type=\"text\" name=\"text-5\" value=\"\" placeholder=\"\" id=\"forminator-field-text-5_6a330bfa8bd03\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-8\" class=\"forminator-field-section forminator-col forminator-col-12\"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Marknavorsing<\/h2><\/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-142__field--select-1_6a330bfa8bd03\" id=\"forminator-form-142__field--select-1_6a330bfa8bd03-label\" class=\"forminator-label\">Hoe het u van ons gehoor<\/label><select multiple id=\"forminator-form-142__field--select-1_6a330bfa8bd03\" class=\"forminator-select--field forminator-select2 forminator-select2-multiple\" data-required=\"\" name=\"select-1[]\" data-default-value=\"\" data-hidden-behavior=\"zero\" data-placeholder=\"\" data-search=\"false\" data-search-placeholder=\"Search\" data-checkbox=\"false\" data-allow-clear=\"true\" aria-labelledby=\"forminator-form-142__field--select-1_6a330bfa8bd03-label\"><option value=\"one\"  data-calculation=\"0\">Word of mouth<\/option><option value=\"two\"  data-calculation=\"0\">Doctor<\/option><option value=\"three\"  data-calculation=\"0\">Internet (Googe)<\/option><option value=\"four\"  data-calculation=\"0\">Facebook page<\/option><option value=\"five\"  data-calculation=\"0\">Instagram page<\/option><option value=\"six\"  data-calculation=\"0\">Online advertising<\/option><option value=\"nine\"  data-calculation=\"0\">Flyers<\/option><option value=\"ten\"  data-calculation=\"0\">Other<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-7\" class=\"forminator-field-section forminator-col forminator-col-12\"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Toestemming en Ooreenkoms<\/h2><\/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_6a330bfa8bd03\" id=\"forminator-field-consent-1_6a330bfa8bd03-label\" class=\"forminator-label\">Aanvaar u die Bepalings en Voorwaardes en Privaatheidsbeleid van Dr. O'Callaghan Dental Care? * <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-checkbox__wrapper\"><label id=\"forminator-field-consent-1_6a330bfa8bd03__label\" class=\"forminator-checkbox forminator-consent\"><input type=\"checkbox\" name=\"consent-1\" id=\"forminator-field-consent-1_6a330bfa8bd03\" value=\"checked\" aria-labelledby=\"forminator-field-consent-1_6a330bfa8bd03-label\" aria-describedby=\"forminator-field-consent-1_6a330bfa8bd03__description\" data-required=\"true\" aria-required=\"true\" \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><\/label><div id=\"forminator-field-consent-1_6a330bfa8bd03__description\" class=\"forminator-checkbox__label forminator-consent__label\"><p>Ja, ek stem saam met die <a href=\"https:\/\/drhenryocal.co.za\/af\/privacy-policy\/\">privaatheidsbeleid<\/a> ,&nbsp;<a rel=\"noopener\" target=\"_blank\" href=\"https:\/\/drhenryocal.co.za\/af\/terms-and-conditions\/\">bepalings en voorwaardes<\/a> en betalingsbeleid. Deur hierdie vorm in te dien, erken ek dat die inligting wat verskaf is na my beste wete waar en korrek is, en ek verstaan \u200b\u200bdat hierdie voorlegging as my digitale handtekening dien. Ek onderneem verder om Dr. O\u2019Callaghan Tandheelkundige Sorg onmiddellik in kennis te stel van enige veranderinge aan die verskafde inligting.<\/p><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"captcha-1\" class=\"forminator-field-captcha forminator-col forminator-col-12\"><div class=\"forminator-captcha-left forminator-g-recaptcha\" data-theme=\"light\"  data-sitekey=\"6LfANLcrAAAAALO2bE-MycjrjkjRlixFTZfSJBt7\" data-size=\"normal\"><\/div> <\/div><\/div><input type=\"hidden\" name=\"referer_url\" value=\"\" \/><div class=\"forminator-row forminator-row-last\"><div class=\"forminator-col\"><div class=\"forminator-field\"><button class=\"forminator-button forminator-button-submit\">Submit Patient Form<\/button><\/div><\/div><\/div><input type=\"hidden\" id=\"forminator_nonce\" name=\"forminator_nonce\" value=\"fe909ee3d0\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/af\/wp-json\/wp\/v2\/pages\/135\" \/><input type=\"hidden\" name=\"form_id\" value=\"142\"><input type=\"hidden\" name=\"page_id\" value=\"135\"><input type=\"hidden\" name=\"form_type\" value=\"default\"><input type=\"hidden\" name=\"current_url\" value=\"https:\/\/drhenryocal.co.za\/af\/medical-documents\/\"><input type=\"hidden\" name=\"render_id\" value=\"0\"><input type=\"hidden\" name=\"action\" value=\"forminator_submit_form_custom-forms\"><input type=\"hidden\" name=\"trp-form-language\" value=\"af\"\/><\/form><\/div>\n\n\n\n<p><\/p>","protected":false},"excerpt":{"rendered":"<p>Please complete the form below before you arrive at the practice for your appointment. All fields marked with a * (red asterisk) are compulsory. Please note that you have to accept and acknowledge the terms of service at the bottom of the form to be able to submit this form and receive treatment. Should you&#8230;<\/p>","protected":false},"author":2,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_themeisle_gutenberg_block_has_review":false,"_kad_post_transparent":"","_kad_post_title":"","_kad_post_layout":"","_kad_post_sidebar_id":"","_kad_post_content_style":"","_kad_post_vertical_padding":"","_kad_post_feature":"","_kad_post_feature_position":"","_kad_post_header":false,"_kad_post_footer":false,"_kad_post_classname":"","footnotes":""},"class_list":["post-135","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/drhenryocal.co.za\/af\/wp-json\/wp\/v2\/pages\/135","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/drhenryocal.co.za\/af\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/drhenryocal.co.za\/af\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/drhenryocal.co.za\/af\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/drhenryocal.co.za\/af\/wp-json\/wp\/v2\/comments?post=135"}],"version-history":[{"count":6,"href":"https:\/\/drhenryocal.co.za\/af\/wp-json\/wp\/v2\/pages\/135\/revisions"}],"predecessor-version":[{"id":149,"href":"https:\/\/drhenryocal.co.za\/af\/wp-json\/wp\/v2\/pages\/135\/revisions\/149"}],"wp:attachment":[{"href":"https:\/\/drhenryocal.co.za\/af\/wp-json\/wp\/v2\/media?parent=135"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}